Chapter 30: Oral Nutrition Nursing School Test Banks

MULTIPLE CHOICE

1. The nurse is admitting a person to the unit and is assessing the patients nutritional status. In assessing the patients nutritional status, the nurse realizes that:

a.

body mass index (BMI) is the main indicator of obesity.

b.

ideal body is the standard gauge for nutritional status.

c.

clinical judgment is required, along with other indicators.

d.

the amount of weight change is the main nutritional indicator.

ANS: C

Use clinical judgment when evaluating muscular patients or patients with large amounts of edema or ascites, because these physiological states will lead to false overestimation of the degree of fatness. BMI alone is not a perfect predictor of overweight or obesity. You gather weight information in several ways, including usual body weight (UBW), ideal body weight (IBW), actual body weight (ABW), and BMI. A thorough nutritional assessment usually requires the collection of all of these weight measures. The magnitude and direction of weight change are more meaningful than standardized weight references when one is dealing with sick or debilitated patients.

DIF: Cognitive Level: Application REF: Text reference: p. 761

OBJ: Perform accurate nutritional screening.

TOP: Anthropometrics/Body Weight KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The nurse is assessing the patient for nutritional status. Which laboratory value may indicate compromised protein status?

a.

Serum albumin level of 4.0 g/dL

b.

Prealbumin level of 12 g/dL

c.

Total lymphocyte count of 1600 cells/mm3

d.

Prealbumin level of 35 g/dL

ANS: B

Prealbumin normally ranges from 20 to 50 mg/dL. This test is useful for monitoring short-term changes in visceral protein (Grodner et al, 2004). It has a short half-life of 2 days. A patient has compromised protein status when levels are between 10 and 15 g/dL. Normal serum albumin values are between 3.5 and 5.0 g/dL. For nutritional analysis, values between 2.8 and 3.5 g/dL indicate compromised protein status. Total lymphocyte count (TLC) is a useful measure of immune function. A normal TLC is greater than 1500 cells/mm3. You must assess a measure of TLC along with other diagnostic indicators. A count of less than 1500/mm3 indicates possible immunocompromise associated with protein-energy malnutrition.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 762

OBJ: Perform accurate nutritional screening. TOP: Prealbumin

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse is caring for a patient diagnosed with severe dehydration. She notes that the patients albumin level is 4.0. What may this indicate?

a.

The patient is in a compromised protein state.

b.

The level may be falsely high.

c.

An acute nutritional deficiency.

d.

A long-term nutritional deficiency.

ANS: B

In patients who are dehydrated or who have received infusions of albumin, fresh frozen plasma, or whole blood, serum albumin levels will appear normal. Normal serum albumin values are between 3.5 and 5.0 g/dL. Albumin is a useful test for monitoring long-term nutrition changes because normal values still may be found among patients who are malnourished. For nutritional analysis, values between 2.8 and 3.5 g/dL indicate compromised protein status. Normal serum albumin values are between 3.5 and 5.0 g/dL.

DIF: Cognitive Level: Analysis REF: Text reference: p. 762

OBJ: Perform accurate nutritional screening. TOP: Albumin

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. The nurse is caring for a patient who requires assistance with eating. The patient repeatedly apologizes to the nurse, saying, Im so sorry. Im like a baby. Im such a burden since I cant even feed myself. What is the most appropriate strategy for the nurse to use?

a.

Feed all of the solid foods first, and then offer liquids.

b.

Feed the patient quickly so as not to make the patient feel like it is taking a great deal of time out of the nurses day.

c.

Minimize conversation so that the patient can eat faster.

d.

Appear unhurried, sit at the bedside, and encourage the patient to feed himself/herself as much as possible.

ANS: D

Meals should be a pleasant event for the patient. Conversation promotes socialization. Adults who need help to eat need compassion and understanding. Given the importance of nutrition in the healing process the nurse should use common sense to provide a socially meaningful mealtime. Feeding the patient quickly is likely to accentuate his belief that he is a burden. It is best to offer fluids after every 3 or 4 bites of solid food, or whenever the patient requests a drink.

DIF: Cognitive Level: Application REF: Text reference: p. 764 |Text reference: p. 767

OBJ: Verbalize the steps used in assisting an adult to eat.

TOP: Assisting the Patient with Oral Nutrition

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

5. What must the nurse do before assisting the patient with feeding?

a.

Assess the patients gag reflex.

b.

Make sure that the consistency of the food is thin.

c.

Remove the patients dentures to prevent gagging.

d.

Prepare the patient to be fed by a staff member.

ANS: A

Assess the patients ability to swallow and the patients gag reflex. Some patients (those who have neurological diseases or who are handicapped) have a reduced gag reflex and/or dysphagia, increasing the risk for aspiration. Changes in the consistency of the diet (thickened liquids, pureed, soft), swallow training, or alternative means of nutrition are often necessary and require a speech therapist or a registered dietitian. If the patient wears dentures, check to ensure that they fit well and are clean. This ensures that the patient is able to chew food and swallow more normally. Patients with any level of independence should not be totally fed by hospital staff. A thorough understanding of the patients physical and cognitive limitations alerts the nurse to the type of assistance the patient needs.

DIF: Cognitive Level: Application REF: Text reference: p. 765

OBJ: Perform accurate nutritional screening.

TOP: Assisting the Patient with Oral Nutrition

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

6. The nurse is caring for an infant who is 3 months old and is being bottle-fed human milk. Will the nurse need to provide the infant with any additional sources of nutrition or fluids?

a.

The infant will need extra water in between feedings.

b.

The infant will need juice in between feedings.

c.

No additional fluids will be needed between meals.

d.

The child will need to start on infant cereal.

ANS: C

Human milk is the most desirable complete diet for infants during the first 6 months. Infants who are breast- or bottle-fed human milk do not require additional fluids, especially water or juice, during the first 4 months of life. Excessive intake of water causes water intoxication, failure to thrive, and hyponatremia. Typically, infants do not consume solid foods until 4 to 6 months of age. Iron-fortified infant cereal is usually the first solid food to be offered.

DIF: Cognitive Level: Application REF: Text reference: p. 768

OBJ: Perform accurate nutritional screening.

TOP: Pediatric Considerations with Oral Feedings

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. What is an appropriate technique for the nurse to use to prevent aspiration when assisting a patient with meals?

a.

Keep the patients head back and straight.

b.

Offer thin-consistency foods.

c.

Provide large amounts of fluids.

d.

Have the patient sit up for 30 minutes after eating.

ANS: D

Ask the patient to remain sitting upright for at least 30 minutes after the meal to reduce the risk for gastroesophageal reflux, which can cause aspiration. The patient must be sitting upright for passage of food through the pharynx and esophagus. Observe the patients ability to ingest foods of various textures and thicknesses to indicate whether aspiration risk is increased with thin liquids. Observe the patient with various consistencies of liquids. Difficulty managing certain foods may indicate dysphagia, and referral to a dietitian is appropriate if a patient has difficulty with a particular consistency.

DIF: Cognitive Level: Application REF: Text reference: p. 772

OBJ: Identify risk factors for aspiration related to dysphagia. TOP: Preventing Aspiration

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8. The patient is admitted with a diagnosis of stroke. The nurse attempts to feed the patient, but the patient coughs and gags when food is placed in his mouth. What should the nurse do to assist this patient?

a.

Feed the patient more slowly.

b.

Feed the patient more quickly.

c.

Contact the speech pathology department.

d.

Ignore the cough and try again later.

ANS: C

If the patient coughs, gags, complains of food stuck in the throat, or has pockets of food in the mouth, the patient may require a swallowing evaluation by a licensed speech pathologist or by videofluoroscopy. Consider consultation with a speech therapist for swallowing exercises and techniques to improve swallowing and reduce risk for aspiration. Notify the physician of any symptoms that occurred during the meal and which foods caused the symptoms.

DIF: Cognitive Level: Application REF: Text reference: p. 769

OBJ: Identify risk factors for aspiration related to dysphagia. TOP: Suspected Dysphagia

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

9. The nurse is caring for a patient who is 6 feet 2 inches tall and weighs 250 pounds. What is the patients body mass index (BMI)?

a.

18.5 kg/m2

b.

30.2 kg/m2

c.

32.13 kg/m2

d.

40.11 kg/m2

ANS: C

BMI = Weight (lb)/Height (inches) Height (inches) 703. In this case, 250/(74 74) 703 250/5476 703 .0457 703 = 32.13 kg/m2.

DIF: Cognitive Level: Analysis REF: Text reference: p. 762

OBJ: Perform accurate nutritional screening. TOP: BMI

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

10. The nurse is caring for a patient who is believed to be suffering from malnutrition. The nurse calculates that the patients body mass index (BMI) is 16.4 kg/m2. What does this indicate about the patients weight?

a.

The patient is underweight.

b.

The patients weight is normal.

c.

The patient is overweight.

d.

The patient is obese (class 1).

ANS: A

Underweight is defined as a BMI <18.5 kg/m2. Normal weight is classified as a BMI between 18.5 and 24.9 kg/m2. Overweight is defined as a BMI between 25 and 29.9 kg/m2. Obesity (class 1) is defined as a BMI between 30 and 34.9 kg/m2.

DIF: Cognitive Level: Analysis REF: Text reference: p. 761

OBJ: Perform accurate nutritional screening. TOP: Underweight

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

11. A patient is admitted to the hospital for evaluation for sleep apnea. The nurse calculates his body mass index (BMI) at 42 kg/m2. What does this indicate about the patients weight?

a.

The patient is overweight.

b.

The patient falls into the class 1 range of obesity.

c.

The patient falls into the class 2 range of obesity.

d.

The patient falls into the class 3 range of extreme obesity.

ANS: D

Extreme obesity (class 3) is defined as a BMI equal to or greater than 40 kg/m2. Overweight is defined as a BMI between 25 and 29.9 kg/m2. Class 1 obesity is defined as a BMI between 30 and 34.9 kg/m2. Class 2 obesity is defined as a BMI between 35 and 39.9 kg/m2.

DIF: Cognitive Level: Analysis REF: Text reference: p. 762

OBJ: Perform accurate nutritional screening. TOP: Extreme Obesity

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

12. The nurse is caring for a patient 2 days after surgery. The ordered diet is a mechanical soft diet. Which of the following foods may the patient choose to eat?

a.

Salad

b.

Baked potato without skin

c.

Cooked cereal

d.

Soft peeled apples

ANS: C

Mechanically altered diets consist of chopped, ground, mashed, or pureed foods for patients who have problems with chewing or swallowing. Consistency can be varied according to the patients own ability to chew or swallow. Small amounts of liquids added to foods contribute to an appropriate consistency. Liquids that are added should complement the food and should not conceal the foods original flavor. Butter, margarine, and honey can be added to increase caloric density. A regular diet with no restrictions could include a salad. A baked potato without the skin or soft peeled apples would be allowed on a dysphagia advanced diet that uses regular food, with the exception of very hard, sticky, or crunchy foods.

DIF: Cognitive Level: Application REF: Text reference: p. 765

OBJ: Perform accurate nutritional screening. TOP: Types of Therapeutic Diets

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

13. The patient is placed on a clear liquid diet after surgery. Which of the following foods may the patient select?

a.

Coffee with milk and sugar

b.

Gelatin, popsicles, apple juice

c.

Water, orange juice, Jell-O

d.

Black coffee, popsicles, ice cream

ANS: B

A clear liquid diet consists of foods that are clear and liquid at room or body temperature (e.g., water, clear fruit juice, gelatin, popsicles). Caution should be exercised with regard to the amount of caffeine received by patients on clear liquids. Coffee with milk, orange juice, and ice cream are not clear liquids.

DIF: Cognitive Level: Application REF: Text reference: p. 765

OBJ: Perform accurate nutritional screening. TOP: Clear Liquid Diet

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

14. Which of the following is a sign of vitamin C deficiency?

a.

Cheilosis (redness/swelling of the lips)

b.

Glossitis

c.

Spongy, bleeding, abnormal redness of the gingiva

d.

Spoon-shaped, brittle, ridged fingernails

ANS: C

Spongy, bleeding gingiva is indicative of inadequate vitamin C intake. Cheilosis, glossitis, and spoon-shaped, brittle, ridged nails are symptoms of iron deficiency.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 760

OBJ: Perform accurate nutritional screening. TOP: Vitamin C Deficiency

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

15. The patient is on the dysphagia puree stage of the national dysphagia diet. Which of the following foods may the patient select?

a.

Mashed potatoes

b.

Dry cereals moistened with milk

c.

Well-cooked noodles in gravy

d.

Well-moistened cereals

ANS: A

The dysphagia puree stage requires foods that are uniform, pureed, and cohesive with a pudding-like texture. Examples include mashed potatoes, pureed meat, pureed pasta, yogurt, and cooked cereals. Dry cereals moistened with milk and well-cooked noodles in gravy are allowed in the dysphagia mechanically altered stage. Well-moistened cereals are allowed in the dysphagia advanced stage.

DIF: Cognitive Level: Analysis REF: Text reference: p. 770

OBJ: Perform accurate nutritional screening. TOP: National Dysphagia Diet

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

16. The nurse is preparing to assess the nutritional status of an 80-year old patient in a long-term care facility. What screening tool would best suit this purpose?

a.

The Malnutrition Universal Screening Tool (MUST)

b.

Mini Nutritional Assessment (MNA)

c.

Anthropometric measurements

d.

A daily nutrition intake log

ANS: B

The Mini Nutritional Assessment (MNA) is specifically designed to meet to the needs of geriatric patients in long term care facilities. The MUST tool is particularly designed for assessing older adults in clinical settings, including acute care. Including anthropomorphic measurements might be part of an assessment as might information from the nutrition intake log , but neither would provide a complete picture in this case.

DIF: Cognitive Level: Application REF: Text reference: p. 755 |Text reference: p. 760

OBJ: Discuss the components and purposes of nutritional assessments and screenings.

TOP: Nutritional Screening Tools KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse is admitting a patient to the medical unit. Which of the following are reasons the nurse may perform a nutritional screening on this patient? (Select all that apply.)

a.

To assess risk for malnutrition

b.

To assist with feeding

c.

To identify risk for aspiration

d.

To determine body weight

ANS: A, B, C

A nurses role includes performing nutritional screening to assess a patients risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding. Although determining body weight is one aspect of assessing nutritional status, it is not the focus of a nutritional screening.

DIF: Cognitive Level: Application REF: Text reference: pp. 754-755

OBJ: Identify and refer patients appropriate for nutritional assessment.

TOP: Nutritional Screening KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. The NCP provides structure for the provision of nutritional care to all patients and provides a framework for the RD to make decisions regarding medical nutrition therapy. The steps involved in this process include which of the following? (Select all that apply.)

a.

Nutrition assessment

b.

Nutrition diagnosis

c.

Nutrition intervention

d.

Nutrition evaluation

ANS: A, B, C, D

In 2003, the American Dietetic Association published the Nutrition Care Process (NCP) and model. This process provides structure for the provision of nutritional care to all patients and provides a framework for the RD to think critically and make decisions regarding medical nutrition therapy. This process consists of four steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 755

OBJ: Perform accurate nutritional screening. TOP: Nutrition Care Process

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. Biochemical indices help the clinician to determine the effects of nutritional factors or of medical conditions on the health status of patients. No single test is available for evaluating short-term response to medical nutritional therapy. Laboratory tests conducted over time will give more accurate information than a single test. Which of the following are the most important biochemical measures? (Select all that apply.)

a.

Ideal body weight

b.

Visceral protein status

c.

Immune function

d.

Percent of weight gain

ANS: B, C

Laboratory tests conducted over time will give more accurate information than a single test. The most important biochemical measures are visceral protein status and immune function. Ideal body weight and percent of weight gain are not biochemical measures.

DIF: Cognitive Level: Comprehension REF: Text reference: p. 762

OBJ: Perform accurate nutritional screening. TOP: Biochemical Indices

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. A stroke patient has residual dysphagia. The nurse notes that the ordered diet is the national dysphagia diet. She knows this diet comprises which of the following? (Select all that apply.)

a.

Dysphagia puree diet

b.

Dysphagia mechanically altered diet

c.

Dysphagia advanced diet

d.

Regular diet

ANS: A, B, C, D

In October 2002, the American Dietetic Association published the National Dysphagia Diet Task Force (NDDTF) National Dysphagia Diet (National Dysphagia Diet Task Force, 2002). The diet consists of four levels: dysphagia puree, dysphagia mechanically altered, dysphagia advanced, and regular.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 770

OBJ: Identify risk factors for aspiration related to dysphagia. TOP: National Dysphagia Diet

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. Which of the following are signs of iron (Fe2+) deficiency? (Select all that apply.)

a.

Pale eye membranes

b.

Cheilosis (redness/swelling) of the lips

c.

Spongy, bleeding gingiva

d.

Glossitis

ANS: A, B, D

Pale eye membranes, cheilosis, and glossitis are all signs of iron deficiency. Spongy, bleeding gingiva is indicative of inadequate vitamin C intake.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 760

OBJ: Perform accurate nutritional screening. TOP: Iron Deficiency

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

COMPLETION

1. A nurses role includes performing ___________________ to assess a patients risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding.

ANS:

nutritional screening

A nurses role includes performing nutritional screening to assess a patients risk status for malnutrition, assessing and assisting an adult patient with feeding, and identifying patients at risk for aspiration during oral feeding.

DIF: Cognitive Level: Knowledge REF: Text reference: pp. 754-755

OBJ: Identify and refer patients appropriate for nutritional assessment.

TOP: Nutritional Screening KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

2. Patients who have a cancer diagnosis, infected or draining wounds, burns, or an elevated temperature for more than 2 days are at elevated _______________ risk.

ANS:

nutritional

Risk factors for potential nutritional problems include cancer diagnoses, infected or draining wounds, burns, and elevated body temperature for more than 2 days. Patients exhibiting these conditions should be assessed for their nutritional status.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 755

OBJ: Identify and refer patients appropriate for nutritional assessment.

TOP: Nutritional Risk KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

3. The nurse will collaborate with a ___________ to develop a nutritional plan for a patient identified as being at nutritional risk.

ANS:

registered dietitian

A registered dietitian is a vital member of the health care team. An RD will assess the patients nutritional status and recommend the intervention that will best address the patients unique nutrition diagnosis.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 755

OBJ: Identify and refer to a registered dietitian patients appropriate for nutritional assessment.

TOP: Registered Dietitian KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity

4. ______________ are measures of height; weight; head, arm, and muscle circumferences; and skinfold thickness.

ANS:

Anthropometrics

Anthropometrics are measures of height; weight; head, arm, and muscle circumferences; and skinfold thickness.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 760

OBJ: Perform accurate nutritional screening. TOP: Anthropometrics

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. _______________ is useful for monitoring short-term changes in visceral protein.

ANS:

Prealbumin

Prealbumin normally ranges from 20 to 50 mg/dL. This test is useful in monitoring short-term changes in visceral protein. It has a short half-life of 2 days.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 726

OBJ: Perform accurate nutritional screening. TOP: Prealbumin

KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. The nurse recognizes that the patient is exhibiting signs of ______________ when she notices that he has difficulty holding food and fluid in his mouth and experiences difficulty moving it to his esophagus.

ANS:

dysphagia

Classic signs of dysphagia include inability to hold food and fluid in the mouth or difficulty moving food into the esophagus. Any condition that produces muscle weakness may result in impairment of the swallowing mechanism. Early recognition of the patients difficulty will allow the nurse to implement aspiration precautions to protect the patient from complications of dysphagia.

DIF: Cognitive Level: Knowledge REF: Text reference: p. 764

OBJ: Define aspiration. TOP: Aspiration

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

OTHER

1. The nurse is caring for a patient who is 48 hours post bowel resection with creation of a colostomy. This morning, the nurse assessed the return of bowel sounds. In what order would this patients diet progress?

a.

Full liquid diet

b.

Regular diet

c.

Clear liquid diet

d.

NPO

e.

Soft diet

ANS:

D, C, A, E, B

The patient has most likely been kept NPO until bowel sounds returned. Once bowel sounds resume, the initial diet will be clear liquids. If clear liquids are tolerated, the patient will advance to a full liquid diet, then to a soft diet, and finally to a regular diet.

DIF: Cognitive Level: Analysis REF: Text reference: p. 760

OBJ: State types of and reasons for special or modified diets. TOP: Types of Diets

KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

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