Chapter 12 - Nutrition and Diet Therapy for Nurses

Tucker and Dauffenbach Chapter 12 Learning Outcome 1 To summarize risk factors that affect nutritional health. The client is an overweight alcoholic who has previously been diagnosed with chronic venous insufficiency. The client has a leg wound that has worsened during the last 6 months. The addition of which of the following sign or symptom indicates that client has a protein deficient diet? Increased serum lipid levels Decreasing muscle mass Anemia Poor bone density Answer: 2 Rationale: Increased serum lipid levels, obesity, and toxic levels of some vitamins indicate the client is suffering from overnutrition. Decreasing muscle mass, poor wound healing, functional decline, immunodeficiency, and poor growth in children are all indicators that the client is suffering from protein-related malnutrition. Anemia and poor bone density would more likely be associated with undernutrition but specifically related to diminished intake of iron or calcium and vitamin D. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application The client has been diagnosed with undernutrition. Which of the following nursing diagnoses would most likely be applied to a client with this condition? Impaired swallowing Fluid volume excess Altered urinary elimination Anticipatory grieving Answer: 1 Rationale: The client with impaired swallowing is the most likely nursing diagnosis associated with undernutrition. People who are unable to ingest or receive enough food or nutrients develop undernutrition. Fluid volume excess is not the best answer. This suggests that the client is overhydrated and may be receiving too many fluids. Altered urinary elimination does not usually impact the development of undernutrition. Anticipatory grieving is a possible answer related to depression and decreased food intake. However, among the nursing diagnoses to choose from, the most appropriate diagnosis is impaired swallowing. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Which of the following statements by a client indicates the client is at risk for undernutrition? (Select all that apply.) “I have been so sad and lonely since my wife died.” “I’ve been taking chemotherapy for lung cancer.” “Each day, I take two doses of multivitamins instead of one.” “My dentures don’t fit well anymore.” “I feel like there are sometimes I cannot stop eating.” Answers: 1, 2, 4 Rationale: People who are prone to developing undernutrition are those that may be unable to eat well due to a medical condition, altered functional status, a poor diet, or a low socioeconomic status. Depression and social isolation place people at risk for undernutrition. Chemotherapy can cause nausea and vomiting which is associated with undernutrition. It is important to have good oral health to be able to chew raw fruits and vegetables and other foods. People who take more than one recommended dose of a multivitamin are more prone to developing overnutrition. People who eat too much food develop issues with overnutrition due to an increased intake of nutrients, calories, saturated fats, vitamins, and minerals. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Comprehension Learning Outcome 2 To differentiate between nutritional screening and nutritional assessment. The client has been admitted to the hospital with aspiration pneumonia after a traumatic brain injury produced an impaired ability to swallow. Which of the following activities is least important to be performed for this client? Nutrition screening activities Nutrition history Head-to-toe physical assessment Laboratory-based diagnostic testing Answer: 1 Rationale: This client has been admitted with aspiration pneumonia and has swallowing difficulties. Nutritional screening activities are provided for clients to determine if a full nutritional assessment is needed. Based on this client’s diagnosis and history, this client needs a full nutritional assessment which includes the nutrition history assessment, physical assessment, and laboratory-based diagnostic testing. Nutritional screening activities would only indicate the client needs a full nutritional assessment. Nursing Process: Assessment Client Need: Safe, Effective Care Environment Cognitive Level: Application The nurse is providing teaching for a client regarding the nutritional assessment. Which of the following statements by the client indicates that adequate learning has occurred? 1. “The head-to-toe assessment portion is the most important piece of the nutrition assessment.” 2. “Diagnostic testing done by the lab can provide the most information about my nutritional status.” 3. “My lab test results can be altered by the medications that I take, not just my nutrition.” 4. “If my lab results are okay, it doesn’t matter what you find in my head-to-toe assessment that is abnormal.” Answer: 3 Rationale: No single piece of the nutritional assessment is more important than another piece. All factors should be evaluated. The nutritional assessment consists of a nutrition history, a head-to-toe physical assessment, and laboratory-based diagnostic testing. Laboratory test results can be influenced by medications, disease, environmental factors, and nutrition. Even if laboratory test results are within normal limits, critical thinking must help the health-care providers create the best nutritional assessment possible for the client. Nursing Process: Evaluation Client Need: Safe, Effective Care Environment Cognitive Level: Analysis The client received a nutritional screening and then a nutritional assessment. Which of the following findings would only be documented during a nutritional assessment? Weight 152 pounds Client is able to swallow without difficulty Client has lost 4 pounds during last 2 weeks Increased albumin level Answer: 4 Rationale: Nutritional screenings are quick and efficient ways to determine if a client requires a full nutritional assessment. Nutritional screens include weight, weight history, and if the client can receive oral nutrition. Nutritional assessments include a nutrition history, physical assessment, and laboratory diagnostic tests. The client’s current weight, recent weight loss, and ability to swallow without difficulty would be assessed during a nutritional screening. A nutritional assessment would include the client’s albumin level, among other diagnostic tests used to assess nutritional status. Nursing Process: Assessment Client Need: Safe Effective Care Environment Cognitive Level: Comprehension Learning Outcome 3 To categorize the major components of a nutritional assessment. During a discussion between the student nurse and nurse about the results of a client’s nutritional assessment, the student nurse asks, “Which one of the pieces of the nutritional assessment is least important?” Of the following responses, which one is the nurse’s best response? “The nutrition history is most important because it helps us understand how the client has been eating.” “The head-to-toe physical assessment is most important because it helps us see how the client’s nutritional status is affecting their body.” “The laboratory-based diagnostic tests are most important because they give us information about something that may be happening within the client’s body that we weren’t able to find during the physical assessment.” “Actually, every piece of the nutritional assessment is important. They have to be used together to paint the most complete picture of the client’s nutritional status.” Answer: 4 Rationale: A nutritional assessment is comprised of the nutrition history, physical assessment, and laboratory diagnostic testing. Each piece provides specific information that must be combined together to create the entire picture about what is happening with the client. No single piece of the assessment is more important than another piece. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application The nurse is performing a nutritional assessment on the client. Which of the following pieces of information will most likely be discovered during the nutrition history? Inadequate consumption of protein Client currently weighs 234 pounds Presence of ascites Hemoglobin level is 11.8 g/dL Answer: 1 Rationale: During a nutrition history, the client provides information to the nurse about what the client has eaten. Inadequate protein consumption would be discovered during the nutrition history, during a focused interview based on what was found during the diet recall and possibly in the food frequency questionnaire. The client’s weight is assessed during a nutritional screening or during the physical assessment of the nutritional assessment. Ascites would be noted during the physical assessment. A decreased hemoglobin value would be discovered during laboratory testing. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application The nurse is performing a nutrition assessment on the client. Which of the following may be documented by the nurse regarding laboratory results? “Client lost 20 pounds during last 2 months.” “Dental caries and poor oral health noted.” “Leukocytosis.” “Client using St. John’s worst daily.” Answer: 3 Rationale: Increased white blood cell count would be found as a laboratory result. Weight loss would most likely be discovered when assessing the weight history during a nutritional screening, nutrition history, or during a physical assessment. Dental caries and poor oral health would be found during a physical assessment. Dietary supplement use would be discovered during the nutrition history. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application The adult client weighs 225 pounds and is 2 meters tall. What is this client’s Body Mass Index? Round your answer to one decimal place. Answer: 25.6 Rationale: The client’s weight must be converted to kilograms. 1 kilogram is equal to 2.2 pounds. The client weighs 102.27 kilograms. The client is 2 meters tall. The formula is to figure the client’s BMI is weight (kilogram) divided by height2 (meters). This client’s BMI is 25.6. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Learning Outcome 4 To relate the components of a nutrition history and techniques for gathering nutrition history data. The nurse is providing nutritional assessments for the following clients. The nurse decides that it would be inappropriate to perform a dietary recall activity with which of the following clients? Client newly diagnosed with emphysema Client with a history of Crohn’s disease Client with polycystic kidney disease Client diagnosed with dementia Answer: 4 Rationale: During a diet recall, the client is prompted to remember all of the foods and beverages that have been ingested by the client over the last 24 hours. The client who has difficulty remembering events may have trouble with this exercise. Clients diagnosed with emphysema, Crohn’s disease, and polycystic kidney disease would be able to provide information about their intake over the last 24 hours; however, the client with early-onset dementia may provide inaccurate or unreliable information during this activity. Nursing Process: Assessment Client Need: Health Maintenance and Promotion Cognitive Level: Application The nurse is creating a nursing care plan for a client. During the nutritional assessment, the nurse learned that the client ate a slice of cake 8–10 times each week. During which of the following components of the assessment was this specific information most likely discovered? Food frequency questionnaire 24-hour diet recall Laboratory measurements Nutritional screening Answer: 1 Rationale: The food frequency questionnaires provide information about the variety of foods that have been consumed over time. The nurse probably learned about the client’s consumption of cake during this component of the assessment. The 24-hour diet recall provides information about what the client has consumed during the last 24 hours. Laboratory measurements might assist the nurse or other health-care providers about the ingestion of fatty or sweet foods (increased lipid levels, increased blood glucose level), but this specific information would most likely come during a self-report by the client. A nutritional screening is used to quickly assess basic information (weight, weight history, and ability to ingest nutrition orally). Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application The nurse is performing a nutritional assessment on a client. Which of the following inquiries is the most appropriate question for the client during a diet recall activity? “What did you eat for lunch?” “What dietary supplements do you take each day?” “Was the fish fried?” “Compared to this container, how big was your glass of chocolate milk?” Answer: 4 Rationale: It is important to be open-minded when assessing your patient. It is not appropriate to assume that they ate any meal. Per the text, the nurse cannot ask the client what they ate for “breakfast,” “lunch,” or “dinner” because it implies that they should have eaten the meal. Nurses should not hint at a “correct” response. The nurse should be self-aware of body language, word choices, and tone of voice. The client should be gently prompted. The nurse should clarify what a dietary supplement is and ask questions about their use by this client. The client should be asked how the item was prepared and not given options about which way the food item was prepared. The nurse cannot assume information about serving sizes. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Learning Outcome 5 To distinguish the anthropometric measurements and physical findings that comprise the physical assessment portion of the nutritional assessment. The client has been diagnosed with anorexia nervosa and is currently receiving treatment. During a physical assessment, which of the following findings indicates the client may be noncompliant with therapeutic interventions? Weight gain of 1 pound since the previous week Urine specific gravity of 1.002 The client opts to wear only a gown when weighed The client verbalizes that treatment is making the client feel better Answer: 2 Rationale: A weight gain of 1 pound over the course of a week for the client indicates treatment may be effective. The client who decides to only wear a gown while being weighed indicates treatment may be effective. Clients with eating disorders who wear heavy clothes or weights in their pockets and underwear exhibit noncompliant behaviors. The client who verbalizes that they feel treatment is making them feel better is possibly receiving effective treatment. However, the client with a low urine-specific gravity is most likely drinking large quantities of water prior to being weighed. This client is displaying noncompliant behavior. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis During nutritional assessments for the following four clients, which of the clients weight history regarding an unplanned change in weight is most significant and has the highest priority for intervention? The client weighed 155 pounds and lost 14 pounds during the last 6 months The client weighed 200 pounds and lost 9 pounds in the last month The client weighed 135 pounds and lost 14 pounds during the last 6 months The client weighed 111 and lost 5 pounds in the last month Answer: 3 Rationale: An unplanned weight loss for a client of 5% or more over the course of 1 month, or 10% or more over the course of 6 months, is significant and requires interventions. The client, who weighed 155 pounds and lost 14 pounds during 6 months, had a weight loss of 9%. The client, who weighed 200 pounds and lost 9 pounds during the last month, had a weight loss of 4.5%. The client, who weighed 111 pounds and lost 5 pounds in the last month, had a weight loss of 4.5%. The client, who weighed 135 pounds and lost 14 pounds during the last 6 months, had a weight loss of 10.4%. This client’s weight loss is significant and would require immediate intervention. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis The nurse is measuring and evaluating waist circumferences to screen for cardiovascular disorders and type 2 diabetes mellitus. For which of the following clients would the nurse find to be most appropriate to use their waist circumference for this purpose? Client diagnosed with cirrhosis Pregnant female client Client diagnosed with Peripheral Arterial Disease Client with pancreatic cancer Answer: 3 Rationale: It is not appropriate to use a client’s waist circumference as a way to screen for cardiovascular diseases and type 2 diabetes mellitus if the client has a medical condition that produces a rotund abdomen. Clients with cirrhosis may have ascites due to low albumin levels. Nurses should not screen pregnant female clients for these disorders with this method. It would be appropriate to screen clients with peripheral arterial disease with this method. It would not be appropriate to use this screening method in clients with pancreatic cancer. Their abdomen may be larger due to the tissue mass within the abdomen. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Learning Outcome 6 To illustrate appropriate laboratory data for use in an assessment. The physician has ordered several laboratory tests for the client as part of a nutritional assessment. Which of the following laboratory tests provide the most accurate information regarding current nutritional status? Prealbumin Albumin Transferrin Total lymphocyte count Answer: 1 Rationale: Albumin, prealbumin, and transferring are classified as plasma proteins. Each of these proteins has a different half-life. Plasma proteins with short half-lives provide more current information about a client’s nutritional status. Albumin has a long half-life, so it is not a very sensitive marker. Transferrin has a shorter half-life than albumin, but it is still not the best marker for nutritional status. Prealbumin’s half-life is the shortest of the three plasma proteins and it can be used to evaluate a client’s current nutritional status. The total lymphocyte count is more useful as a way to measure immunocompetence and is not used to measure a client’s nutritional status. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application The client has noticed increased bruising and a decreased ability to clot after injuries. The client admits taking ginseng, to deal with occupational stress, and a baby aspirin each day. Which of the following interventions should be included in this client’s nursing care plan? Encourage client to discontinue use of baby aspirin Encourage the client to discuss the use of dietary supplements with the health-care provider Encourage the client to begin consuming foods that are rich in vitamin K Encourage the client to discuss emotional stressors Answer: 2 Rationale: This client is taking aspirin and ginseng. Both of these substances increase bleeding times which result in bruising and an inability to clot after injuries. The client should be encouraged to discuss the use of supplements with the primary health-care provider in order to prevent further interactions between medications and dietary supplements. The client should not be encouraged to consume foods rich in vitamin K to induce better clotting. The greatest priority rests with reducing the problems presented by the dietary supplement. The client should be encouraged to discuss emotional stressors later, but at this time it is most important to address the decreased ability to clot. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application The nurse is performing a nutritional assessment for an older adult who takes no medications. Which of the following laboratory values is of most concern to the nurse? Albumin 4.2 gm/L Prealbumin 322 mg/L Transferrin 400 mg/dL Cholesterol 114 mg/dL Answer: 4 Rationale: Normal albumin levels are 3.5–5.0 gm/L. Normal prealbumin levels are 150–350 mg/L. Normal transferrin levels are above 200 mg/L. Decreased cholesterol levels in older adults, who do not take cholesterol-lowering medications, are associated with an increased risk of morbidity and mortality. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Learning Outcome 7 To differentiate between normal and abnormal findings in a nutritional assessment. The nurse is assessing a client using the Nutritional Screening Initiative Tool. Which of the following would increase the client’s score on this screening tool? Takes Lopressor (atenolol) daily Maintained weight over last 7 years within 5 pounds Receives visits from daughter and grandchildren three times each week Requires assistance of one person to bathe Answer: 4 Rationale: An increased score on this screening tool may indicate undernutriton. The client who takes multiple medications, not one medication daily, is at a higher risk for undernutrition. The client who has maintained their weight does not have an increased risk for undernutrition. The client who has adequate social contact does not have an increased risk for undernutrition. The client who requires assistance with self care does have an increased risk for undernutrition. Nursing Process: Assessment Client Need: Health Maintenance and Promotion Cognitive Level: Application The elderly client is on Medicare and lives in a Medicare-certified long-term care facility. Which of the following is the most appropriate nutritional assessment tool to use for this client? Minimum Data Set Nutrition Screening Initiative Malnutrition Universal Screening Tool MyPyramid Answer: 1 Rationale: All clients receiving Medicare and living in a Medicare-certified health-care facility must be assessed using the Minimum Data Set. The Nutrition Screening Initiative is used for older adults. The Malnutrition Universal Screening Tool is used in adults for screening purposes only. MyPyramid is not an assessment or screening tool. It is used to quickly assess food intake and compare to dietary recommendations. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Comprehension The client is a child. The parents are requesting information about how to ensure the client is eating an appropriate diet. Which of the following is the best response by the nurse? “The Malnutrition Universal Screening Tool would be good to use with your child and it is really easy to perform.” “The Nutrition Screening Initiative would be just right and it’s easy to use.” “MyPyramid would be a great way to find out if your child is getting the right amount of food and nutrients.” “The Mini Nutrition Assessment is easy to use and it is online.” Answer: 3 Rationale: The only appropriate way to quickly assess a child’s nutritional intake is with MyPyramid based on the Dietary Guidelines for Americans. All of other assessment screening tools are for use with adults or older adults. The Malnutrition Universal Screening Tool, the Nutrition Screening Initiative, and the Mini Nutrition Assessment are all easy to use. The Mini Nutrition Assessment is online. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application 4. The young client has been admitted into the hospital with a smooth, bright red tongue, sores on the lips and in the corners of the mouth, and pallor. Which of the following dietary deficiencies does the nurse expect to discover during the nutritional assessment? Riboflavin Iron Vitamin D Vitamin A Niacin Answers: 1, 2, 5 Rationale: Dietary deficiency of riboflavin would account for the smooth, bright red tongue and sores on the client’s lips. An iron-deficiency is associated with pale skin and mucous membranes. Vitamin D deficiency is associated with rickets and poor bone and teeth development. Vitamin A deficiency is associated with skin disorders such as follicular hyperkeratosis. Dietary deficiency of niacin would account for the smooth, bright red tongue and sores on the client’s lips. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Learning Outcome 8 To strategize how to incorporate a nutritional assessment into the nursing process. The client has been admitted to the hospital with anorexia nervosa and severe weight loss. The client is requesting help with dietary planning. Which of the following nursing diagnoses has the highest priority and is the most appropriate for this client? Imbalanced nutrition: less than body requirements Altered role performance Altered thought processes Impaired swallowing Answer: 1 Rationale: This client’s most important nursing diagnosis is “imbalanced nutrition: less than body requirements.” When clients enter the hospital, they often experience difficulty adjusting to an “altered role.” It is possible that altered thought processes causes this health condition, but this is not the best response. And, impaired swallowing would be a physiological basis for a problem with poor nutritional intake. This does not apply to this client. Nursing Process: Planning Client Need: Safe, Effective Care Environment Cognitive Level: Application The client has requested information from the nurse about how to lose weight. Which of the following is an appropriate client goal? Weight loss of 6% of current body weight in one month Weight loss of 12% of current body weight in 6 months Participate in 75 minutes of aerobic activity each day Verbalize methods to reduce weight through dietary planning Answer: 4 Rationale: Losing more than 5% in one month or more than 10% of their weight in 6 months is too drastic. Thirty minutes of aerobic activity each day is enough to help a client lose weight. Not every client can tolerate 75 minutes of physical activity each day. It would be appropriate to expect the client to verbalize methods to reduce their weight through dietary planning. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application The overweight client has expressed interest in losing weight to the nurse. Which of the following interventions should the nurse provide for this client? Assist client in developing a dietary plan that reduces caloric intake by 750 calories per day Obtain daily laboratory values Assist client to maintain a food and activity diary for 6 months Assist client to plan for ways to reduce the amount of time that is spent sitting each day Answer: 4 Rationale: This client should be assisted to initially reduce dietary intake by 500 calories per day. Laboratory values do not need to be obtained this frequently. A food and activity diary should be maintained for one week. There is no reason to assess this information for 6 months. The client should be assisted to plan ways to decrease the amount of time that is spent sitting each day. Physical activity can be increased per advisement of the client’s primary health-care provider. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Application 16 ©2011 by Education, Inc. Tucker/Dauffenbach, Test Item File for Nutrition and Diet Therapy for Nurses