C 11

Chapter 11: Nutritional Assessment
Jarvis: Physical Examination & Health Assessment, 7th Edition
MULTIPLE CHOICE
1. The nurse recognizes which of these persons is at greatest risk for undernutrition?
a. 5-month-old infant
b. 50-year-old woman
c. 20-year-old college student
d. 30-year-old hospital administrator
ANS: A
Vulnerable groups for undernutrition are infants, children, pregnant women, recent
immigrants, persons with low incomes, hospitalized people, and aging adults.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 181

MSC: Client Needs: Health Promotion and Maintenance
2. When assessing a patients nutritional status, the nurse recalls that the best definition of
optimal nutritional status is sufficient nutrients that:
a. Are in excess of daily body requirements.
b. Provide for the minimum body needs.
c. Provide for daily body requirements but do not support increased metabolic
demands.
d. Provide for daily body requirements and support increased metabolic demands.
ANS: D
Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-
to-day body needs and any increased metabolic demands resulting from growth, pregnancy, or
illness.

3. The nurse is providing nutrition information to the mother of a 1-year-old child. Which of
these statements represents accurate information for this age group?
a. Maintaining adequate fat and caloric intake is important for a child in this age
group.
b. The recommended dietary allowances for an infant are the same as for an
adolescent.
c. The babys growth is minimal at this age; therefore, caloric requirements are
decreased.
d. The baby should be placed on skim milk to decrease the risk of coronary artery
disease when he or she grows older.
ANS: A
Because of rapid growth, especially of the brain, both infants and children younger than 2
years of age should not drink skim or low-fat milk or be placed on low-fat diets. Fats (calories
and essential fatty acids) are required for proper growth and central nervous system
development.
DIF: Cognitive Level: Applying (Application) REF: pp. 181-182
4. A pregnant woman is interested in breastfeeding her baby and asks several questions about the
topic. Which information is appropriate for the nurse to share with her?
a. Breastfeeding is best when also supplemented with bottle feedings.
b. Babies who are breastfed often require supplemental vitamins.
c. Breastfeeding is recommended for infants for the first 2 years of life.
d. Breast milk provides the nutrients necessary for growth, as well as natural
immunity.
ANS: D
Breastfeeding is recommended for full-term infants for the first year of life because breast
milk is ideally formulated to promote normal infant growth and development, as well as
natural immunity. The other statements are not correct.
DIF: Cognitive Level: Applying (Application) REF: p. 181

5. A mother and her 13-year-old daughter express their concern related to the daughters recent
weight gain and her increase in appetite. Which of these statements represents information the
nurse should discuss with them?
a. Dieting and exercising are necessary at this age.
b. Snacks should be high in protein, iron, and calcium.
c. Teenagers who have a weight problem should not be allowed to snack.
d. A low-calorie diet is important to prevent the accumulation of fat.
ANS: B
After a period of slow growth in late childhood, adolescence is characterized by rapid physical
growth and endocrine and hormonal changes. Caloric and protein requirements increase to
meet this demand. Because of bone growth and increasing muscle mass (and, in girls, the
onset of menarche), calcium and iron requirements also increase.

6. The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country

who has been in the United States for 1 month. Which of these problems related to his
nutritional status might the nurse expect to find?
a. Obesity
b. Hypotension
c. Osteomalacia (softening of the bones)
d. Coronary artery disease
ANS: C
General undernutrition, hypertension, diarrhea, lactose intolerance, osteomalacia, scurvy, and
dental caries are among the more common nutrition-related problems of new immigrants from
developing countries.

7. For the first time, the nurse is seeing a patient who has no history of nutrition-related
problems. The initial nutritional screening should include which activity?
a. Calorie count of nutrients
b. Anthropometric measures
c. Complete physical examination
d. Measurement of weight and weight history
ANS: D
Parameters used for nutrition screening typically include weight and weight history,
conditions associated with increased nutritional risk, diet information, and routine laboratory
data. The other responses reflect a more in-depth assessment rather than a screening.

8. A patient is asked to indicate on a form how many times he eats a specific food. This method
describes which of these tools for obtaining dietary information?
a. Food diary
b. Calorie count
c. 24-hour recall
d. Food-frequency questionnaire
ANS: D
With this tool, information is collected on how many times per day, week, or month the
individual eats particular foods, which provides an estimate of usual intake.

9. The nurse is providing care for a 68-year-old woman who is complaining of constipation.
What concern exists regarding her nutritional status?
a.Absorption of nutrients may be impaired.
b.Constipation may represent a food allergy.
c.The patient may need emergency surgery to correct the problem.
d.Gastrointestinal problems will increase her caloric demand.
ANS: A
Gastrointestinal symptoms such as vomiting, diarrhea, or constipation may interfere with
nutrient intake or absorption. The other responses are not correct.

10. During a nutritional assessment, why is it important for the nurse to ask a patient what
medications he or she is taking?
a.Certain drugs can affect the metabolism of nutrients.
b.The nurse needs to assess the patient for allergic reactions.
c.Medications need to be documented in the record for the physicians review.
d.Medications can affect ones memory and ability to identify food eaten in the last
24 hours.
ANS: A
Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs,
steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their
digestion, absorption, metabolism, or use. The other responses are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 186

11. A patient tells the nurse that his food simply does not have any taste anymore. The nurses
best response would be:
a. That must be really frustrating.
b. When did you first notice this change?
c. My food doesnt always have a lot of taste either.
d. Sometimes that happens, but your taste will come back.
ANS: B
With changes in appetite, taste, smell, or chewing or swallowing, the examiner should ask
about the type of change and when the change occurred. These problems interfere with
adequate nutrient intake. The other responses are not correct.

12. The nurse is performing a nutritional assessment on a 15-year-old girl who tells the nurse that
she is so fat. Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The
nurses appropriate response would be:
a. How much do you think you should weigh?
b. Dont worry about it; youre not that overweight.
c. The best thing for you would be to go on a diet.
d. I used to always think I was fat when I was your age.
ANS: A
Adolescents increased body awareness and self-consciousness may cause eating disorders
such as anorexia nervosa or bulimia, conditions in which the real or perceived body image
does not favorably compare with an ideal image. The nurse should not belittle the adolescents
feelings, provide unsolicited advice, or agree with her.

13. The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of
these foods are recommended?
a. Foods that the child will eat, no matter what they are
b. Foods easy to hold such as hot dogs, nuts, and grapes
c. Any foods, as long as the rest of the family is also eating them
d. Finger foods and nutritious snacks that cannot cause choking
ANS: D
Small portions, finger foods, simple meals, and nutritious snacks help improve the dietary
intake of young children. Foods likely to be aspirated should be avoided (e.g., hot dogs, nuts,
grapes, round candies, popcorn).
14. The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these
factors will most likely affect the nutritional status of an older adult?
a. Increase in taste and smell
b. Living alone on a fixed income
c. Change in cardiovascular status
d. Increase in gastrointestinal motility and absorption
ANS: B
Socioeconomic conditions frequently affect the nutritional status of the aging adult; these
factors should be closely evaluated. Physical limitations, income, and social isolation are
frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and
smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular
status is not a factor that affects an older adults nutritional status.

15. When considering a nutritional assessment, the nurse is aware that the most common
anthropometric measurements include:
a. Height and weight.
b. Leg circumference.
c. Skinfold thickness of the biceps.
d. Hip and waist measurements.
ANS: A
The most commonly used anthropometric measures are height, weight, triceps skinfold
thickness, elbow breadth, and arm and head circumferences.
DIF: Cognitive Level: Remembering (Knowledge) REF: pp. 189-190

16. If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to
be 120 pounds, then how would the nurse classify the womans weight?
a. Obese
b. Mildly overweight
c. Suffering from malnutrition
d. Within appropriate range of ideal weight
ANS: A
Obesity, as a result of caloric excess, refers to weight more than 20% above ideal body
weight. For this patient, 20% of her ideal body weight would be 24 pounds, and greater than
20% of her body weight would be over 144 pounds. Therefore, having a weight of 156 pounds
would be considered obese.

17. How should the nurse perform a triceps skinfold assessment?

a. After pinching the skin and fat, the calipers are vertically applied to the fat fold.
b. The skin and fat on the front of the patients arm are gently pinched, and then the
calipers are applied.
c. After applying the calipers, the nurse waits 3 seconds before taking a reading. After
repeating the procedure three times, an average is recorded.
d. The patient is instructed to stand with his or her back to the examiner and arms
folded across the chest. The skin on the forearm is pinched.
ANS: C
While holding the skinfold, the lever of the calipers is released. The nurse waits 3 seconds and
then takes a reading. This procedure should be repeated three times, and an average of the
three skinfold measurements is then recorded.

18. In teaching a patient how to determine total body fat at home, the nurse includes instructions
to obtain measurements of:
a. Height and weight.
b. Frame size and weight.
c. Waist and hip circumferences.
d. Mid-upper arm circumference and arm span.
ANS: A
Body mass index, calculated by using height and weight measurements, is a practical marker
of optimal weight for height and an indicator of obesity. The other options are not correct.

19. The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip
ratios. Which one of these patients would be at increased risk?
a. 29-year-old woman whose waist measures 33 inches and hips measure 36 inches
b. 32-year-old man whose waist measures 34 inches and hips measure 36 inches
c. 38-year-old man whose waist measures 35 inches and hips measure 38 inches
d. 46-year-old woman whose waist measures 30 inches and hips measure 38 inches
ANS: A
The waist-to-hip ratio assesses body fat distribution as an indicator of health risk. A waist-to-
hip ratio of 1.0 or greater in men or 0.8 or greater in women is indicative of android (upper
body obesity) and increasing risk for obesity-related disease and early death. The 29-year-old
woman has a waist-to-hip ratio of 0.92, which is greater than 0.8. The 32-year-old man has a
waist-to-hip ratio of 0.94; the 38-year-old man has a waist-to-hip ratio of 0.92; the 46-year-old
woman has a waist-to-hip ratio of 0.78.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 190

20. A 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the
clinic to find out about her laboratory results. What would be important for the nurse to
include in patient teaching in relation to these tests?
a. The risks of undernutrition should be included.
b. Offer methods to reduce the stress in her life.
c. Provide information regarding a diet low in saturated fat.
d. This condition is hereditary; she can do nothing to change the levels.
ANS: C
The patient with elevated cholesterol and triglyceride levels should be taught about eating a
healthy diet that limits the intake of foods high in saturated fats or trans fats. Reducing dietary
fats is part of the treatment for this condition. The other responses are not pertinent to her
condition.

21. In performing an assessment on a 49-year-old woman who has imbalanced nutrition as a result
of dysphagia, which data would the nurse expect to find?
a. Increase in hair growth
b. Inadequate nutrient food intake
c. Weight 10% to 20% over ideal
d. Sore, inflamed buccal cavity
ANS: B
Dysphagia, or impaired swallowing, interferes with adequate nutrient intake.

22. A 21-year-old woman has been on a low-protein liquid diet for the past 2 months. She has had
adequate intake of calories and appears well nourished. After further assessment, what would
the nurse expect to find?
a. Poor skin turgor
b. Decreased serum albumin
c. Increased lymphocyte count
d. Triceps skinfold less than standard
ANS: B
Kwashiorkor (protein malnutrition) is due to diets that may be high in calories but contain
little or no protein (e.g., low-protein liquid diets, fad diets, and long-term use of dextrose-
containing intravenous fluids). The serum albumin would be less than 3.5 g/dL.

23. The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows
that physiologic changes can directly affect the nutritional status of the older adult and
include:
a. Slowed gastrointestinal motility.
b. Hyperstimulation of the salivary glands.
c. Increased sensitivity to spicy and aromatic foods.
d. Decreased gastrointestinal absorption causing esophageal reflux.
ANS: A
Normal physiologic changes in aging adults that affect nutritional status include slowed
gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste
sensitivity, decreased saliva production, decreased visual acuity, and poor dentition.

24. Which of these interventions is most appropriate when the nurse is planning nutritional
interventions for a healthy, active 74-year-old woman?
a. Decreasing the amount of carbohydrates to prevent lean muscle catabolism
b. Increasing the amount of soy and tofu in her diet to promote bone growth and
reverse osteoporosis
c. Decreasing the number of calories she is eating because of the decrease in energy
requirements from the loss of lean body mass
d. Increasing the number of calories she is eating because of the increased energy
needs of the older adult
ANS: C
Important nutritional features of the older years are a decrease in energy requirements as a
result of loss of lean body mass, the most metabolically active tissue, and an increase in fat
mass.

25. A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss.
The nurse determines that many of her complaints may be related to erratic eating patterns,
eating predominantly fast foods, and high caffeine intake. In this situation, which is most
appropriate when collecting current dietary intake information?
a. Scheduling a time for direct observation of the adolescent during meals
b. Asking the patient for a 24-hour diet recall, and assuming it to be reflective of a
typical day for her
c. Having the patient complete a food diary for 3 days, including 2 weekdays and 1
weekend day
d. Using the food frequency questionnaire to identify the amount of intake of specific
foods
ANS: C
Food diaries require the individual to write down everything consumed for a certain time
period. Because of the erratic eating patterns of this individual, assessing dietary intake over a
few days would produce more accurate information regarding eating patterns. Direct
observation is best used with young children or older adults.

26. The nurse is preparing to measure fat and lean body mass and bone mineral density. Which
tool is appropriate?
a. Measuring tape
b. Skinfold calipers
c. Bioelectrical impedance analysis (BIA)
d. Dual-energy x-ray absorptiometry (DEXA)
ANS: D
DEXA measures both bone mineral density and fat and lean body mass. BIA measures fat and
lean body mass but not bone mineral density. A measuring tape measures distance or length,
and skinfold calipers are used to determine skinfold thickness.

27. Which of these conditions is due to an inadequate intake of both protein and calories?
a. Obesity
b. Bulimia
c. Marasmus
d. Kwashiorkor
ANS: C
Marasmus, protein-calorie malnutrition, is due to an inadequate intake of protein and calories
or prolonged starvation. Obesity is due to caloric excess; bulimia is an eating disorder.
Kwashiorkor is protein malnutrition.

MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
28. During an assessment of a patient who has been homeless for several years, the nurse notices
that his tongue is magenta in color, which is an indication of a deficiency in what mineral
and/or vitamin?
a. Iron
b. Riboflavin
c. Vitamin D and calcium
d. Vitamin C
ANS: B
Magenta tongue is a sign of riboflavin deficiency. In contrast, a pale tongue is probably
attributable to iron deficiency. Vitamin D and calcium deficiencies cause osteomalacia in
adults, and a vitamin C deficiency causes scorbutic gums.

29. A 50-year-old patient has been brought to the emergency department after a housemate found
that the patient could not get out of bed alone. He has lived in a group home for years but for
several months has not participated in the activities and has stayed in his room. The nurse
assesses for signs of undernutrition, and an x-ray study reveals that he has osteomalacia,
which is a deficiency of:
a. Iron.
b. Riboflavin.
c. Vitamin D and calcium.
d. Vitamin C.
ANS: C
Osteomalacia results from a deficiency of vitamin D and calcium in adults. Iron deficiency
would result in anemia, riboflavin deficiency would result in magenta tongue, and vitamin C
deficiency would result in scurvy.

30. An older adult patient in a nursing home has been receiving tube feedings for several months.
During an oral examination, the nurse notes that patients gums are swollen, ulcerated, and
bleeding in some areas. The nurse suspects that the patient has what condition?
a. Rickets
b. Vitamin A deficiency
c. Linoleic-acid deficiency
d. Vitamin C deficiency
ANS: D
Vitamin C deficiency causes swollen, ulcerated, and bleeding gums, known as scorbutic gums.
Rickets is a condition related to vitamin D and calcium deficiencies in infants and children.
Linoleic-acid deficiency causes eczematous skin. Vitamin A deficiency causes Bitot spots and
visual problems.

31. The nurse is assessing the body weight as a percentage of ideal body weight on an adolescent
patient who was admitted for suspected anorexia nervosa. The patients usual weight was 125
pounds, but today she weighs 98 pounds. The nurse calculates the patients ideal body weight
and concludes that the patient is:
a. Experiencing mild malnutrition.
b. Experiencing moderate malnutrition.
c. Experiencing severe malnutrition.
d. Still within expected parameters with her current weight.
ANS: B
By dividing her current weight by her usual weight and then multiplying by 100, a percentage
of 78.4% is obtained, which means that her current weight is 78.4% of her ideal body weight.
A current weight of 80% to 90% of ideal weight suggests mild malnutrition; a current weight
of 70% to 80% of ideal weight suggests moderate malnutrition; a current weight of less than
70% of ideal weight suggests severe malnutrition.

MULTIPLE RESPONSE
1. The nurse is assessing a patient who is obese for signs of metabolic syndrome. This condition
is diagnosed when three or more certain risk factors are present. Which of these assessment
findings are risk factors for metabolic syndrome? Select all that apply.
a. Fasting plasma glucose level less than 100 mg/dL
b. Fasting plasma glucose level greater than or equal to 110 mg/dL
c. Blood pressure reading of 140/90 mm Hg
d. Blood pressure reading of 110/80 mm Hg
e. Triglyceride level of 120 mg/dL
ANS: B, C
Metabolic syndrome is diagnosed when three or more of the following risk factors are present:
(1) fasting plasma glucose level greater than or equal to 100 mg/dL; (2) blood pressure greater
than or equal to 130/85 mm Hg; (3) waist circumference greater than or equal to 40 inches for
men and 35 inches for women; (4) high-density lipoprotein cholesterol less than 40 in men
and less than 50 in women; and (5) triglyceride levels greater than or equal to 150 mg/dL
(ATP III, 2001).

SHORT ANSWER
1. A patient has been unable to eat solid food for 2 weeks and is in the clinic today complaining
of weakness, tiredness, and hair loss. The patient states that her usual weight is 175 pounds,
but today she weighs 161 pounds. What is her recent weight change percentage? To calculate
recent weight change percentage, use this formula:
Usual weight current weight 100
usual weight
ANS:
8%
175 161 = 14 pounds
14 175 = 0.08
0.08 100 = 8%


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Chapter 11: Nutritional Assessment

Jarvis: Physical Examination & Health Assessment, 7th Edition

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 181

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 181

DIF: Cognitive Level: Applying (Application) REF: p. 181

DIF: Cognitive Level: Applying (Application) REF: p. 182

6. The nurse is assessing a 30-year-old unemployed immigrant from an underdeveloped country

DIF: Cognitive Level: Applying (Application) REF: p. 183

DIF: Cognitive Level: Applying (Application) REF: p. 184

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 184

DIF: Cognitive Level: Applying (Application) REF: p. 182

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 186

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 185

DIF: Cognitive Level: Applying (Application) REF: p. 187

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 183

DIF: Cognitive Level: Remembering (Knowledge) REF: pp. 189-190

DIF: Cognitive Level: Applying (Application) REF: p. 190

17. How should the nurse perform a triceps skinfold assessment?

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 191

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 190

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 190

DIF: Cognitive Level: Applying (Application) REF: p. 182

DIF: Cognitive Level: Applying (Application) REF: p. 185

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 194

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 182

DIF: Cognitive Level: Applying (Application) REF: p. 182

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 184

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 191

DIF: Cognitive Level: Remembering (Knowledge) REF: p. 194

DIF: Cognitive Level: Applying (Application) REF: p. 196

DIF: Cognitive Level: Applying (Application) REF: p. 189

DIF: Cognitive Level: Applying (Application) REF: p. 189

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 189

DIF: Cognitive Level: Applying (Application) REF: p. 197

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 189

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