Nursing Fundamentals: Applying the Nursing Process

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Questions and Answers

What is a sign of good integumentary health?

Dry skin

Poor skin turgor

Edema

Supple texture (correct)

Which symptom indicates a potential issue with gastrointestinal health?

Diarrhea (correct)

Bowel sounds present in all quadrants

Normal stool quality

Absence of nausea

What is considered an abnormal respiratory finding?

No respiratory distress

Clear lung sounds

Normal respiratory rate

Shortness of breath (correct)

What is the primary focus of a nutritional assessment?

To determine a patient's nutritional status and risk factors Signup and view all the answers

What characteristic would indicate poor neurological function?

Numbness or tingling Signup and view all the answers

Which method is NOT commonly used to collect subjective data in a nutritional assessment?

Time-based symptom tracking Signup and view all the answers

Which option represents a normal cardiac finding?

Capillary refill < 3 seconds Signup and view all the answers

Which of the following is an important component of the subjective assessment in a nutritional assessment?

24-hour diet recall Signup and view all the answers

What must a nurse verify about subjective information collected during a nutritional assessment?

That it is accurate and current Signup and view all the answers

Which symptom suggests an eye health issue?

Impaired night vision Signup and view all the answers

What type of dietary information is valuable in identifying nutritional risk factors?

Food purchasing habits Signup and view all the answers

What detail about a patient's food preferences is essential during the subjective assessment?

Cultural dietary practices Signup and view all the answers

Which aspect of a nutritional assessment helps identify food-related health risks?

Food allergies and special diets Signup and view all the answers

During a nutritional assessment, why is it important to include meal timing information?

To understand the impact on digestion and metabolism Signup and view all the answers

What can a history of anorexia or bulimia lead to in a patient?

Electrolyte disturbances Signup and view all the answers

Which of the following is NOT a risk factor for nutritional deficiencies?

Low physical activity Signup and view all the answers

During a physical examination, which observation indicates a well-nourished patient?

BMI within the normal range Signup and view all the answers

Which BMI category is indicated by a BMI of 26?

Overweight Signup and view all the answers

What is a critical finding that may require immediate notification of a healthcare provider?

Significant weight loss noted Signup and view all the answers

How is BMI calculated using pounds and inches?

BMI = (weight (pounds) x 703) / height (inches)^2 Signup and view all the answers

What trend should be observed in the growth charts for infants and children?

Consistent height and weight increase Signup and view all the answers

What is the role of recognizing nutritional risks during assessment?

To anticipate problems and identify complications Signup and view all the answers

Study Notes

Nursing Process in Nutritional Assessment

Nutritional assessment is critical for identifying an individual's nutritional status and risk factors for imbalances.
Begins with a review of the medical record and includes patient interviews, physical exams, and lab results.

Subjective Assessment

Involves obtaining information through interviews with patients or their family members.
Key areas to explore include:
- Age, sex, medical history including chronic diseases and surgeries.
- Dietary habits: 24-hour diet recall, food preferences, cultural practices.
- Special diets, food allergies, cooking, and shopping activities.
Verification of subjective data is essential due to potential inaccuracies in records.
Recognizing risk factors like eating disorders or substance use is vital for anticipating nutritional issues.

Objective Assessment

Involves direct observation during physical examinations through inspection, auscultation, and palpation.
Assess general appearance, including skin color, hair texture, and energy levels to gauge nutritional status.
Measurements of height and weight should be documented and compared to BMI standards for adults and growth charts for children.

Body Mass Index (BMI)

BMI is calculated using formulas:
- BMI = weight (kg) / height (m)^2
- BMI = (weight (lbs) x 703) / height (in)^2
BMI classifications include:
- Underweight: < 18.5
- Desirable: 18.5 - 24.9
- Overweight: 25 - 29.9
- Obese: ≥ 30

Expected vs. Unexpected Findings

Analysis of subjective and objective assessments helps identify expected versus unexpected findings.
Critical conditions are highlighted for immediate healthcare provider notification.

Key Findings to Monitor

General appearance: Energetic and nourished versus lethargic or weight extremes.
Eyes: Normal moisture versus impaired vision or dryness.
Mouth: Intact mucosa versus dryness or difficulty swallowing.
Extremities: Good skin turgor versus edema or dryness.
Neurological: Normal cognition versus confusion or numbness.
Cardiac: Normal heart tones versus arrhythmias or abnormal pulses.
Respiratory: Clear sounds versus distress or abnormal breathing.
Gastrointestinal: Normal stool frequency versus constipation or diarrhea.
Urinary: Normal output versus decreased urine production.

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Description

This quiz focuses on applying the nursing process in the context of basic nutritional concepts and dietary guidelines. It covers essential factors that affect nutritional status, promoting an understanding of how nurses can effectively assess and implement care related to nutrition.