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1. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?
- A. severity of illness
- B. presence of pressure sores
- C. localized edema
- D. generalized weakness
Correct answer: D
Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.
2. The nurse is caring for an infant whose parent reports the infant takes a bottle to go to sleep. What should the nurse instruct to prevent baby bottle tooth decay?
- A. Water
- B. Milk
- C. Iron-fortified formula
- D. Unsweetened fruit juice
Correct answer: A
Rationale: The correct answer is A, Water. Water is recommended to prevent baby bottle tooth decay caused by sugary substances present in milk, formula, or fruit juice. Water does not contain sugars that can contribute to tooth decay, unlike the other options. Milk, formula, and unsweetened fruit juice can all lead to tooth decay if the baby falls asleep with them in their mouth, as the sugars can linger on the teeth and cause decay over time. Iron-fortified formula, although beneficial for the infant's nutrition, still contains sugars that can be harmful to the teeth.
3. This special form is used when the patient is admitted to the unit. The nurse completes the information in this record particularly his/her basic personal data, current illness, previous health history, health history of the family, emotional profile, environmental history as well as physical assessment together with nursing diagnosis on admission. What do you call this record?
- A. Nursing Kardex
- B. Nursing Health History and Assessment Worksheet
- C. Medicine and Treatment Record
- D. Discharge Summary
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
4. In PEM, which condition is characterized by symptoms such as muscle weakness, hanging skin, delayed tooth eruption, and changes in saliva?
- A. Marasmus
- B. Kwashiorkor
- C. Anemia
- D. Noma
Correct answer: A
Rationale: The correct answer is Marasmus. Marasmus is a severe form of protein-energy malnutrition (PEM) that leads to muscle wasting, hanging skin, delayed growth, and changes in saliva. These symptoms are commonly seen in vulnerable populations such as children, homeless individuals, older adults, and substance abusers. Kwashiorkor, on the other hand, is characterized by edema, a distended belly, and skin lesions. Anemia is a condition characterized by a low red blood cell count, leading to fatigue and weakness. Noma is a severe infection affecting the face, particularly the mouth and jaw area.
5. Each of the following accurately describes aspects of the dietary reference intakes (DRIs) published by the Food and Nutrition Board of the Institute of Medicine (IOM) except one. Which one is the exception?
- A. The DRIs replace the older recommended daily allowances
- B. Current DRIs attempt to estimate required nutrients to improve long-term health
- C. DRIs specifically address individuals whose requirements are affected by a disease state
- D. The DRIs attempt to establish maximum safe levels of tolerance for nutrients
Correct answer: C
Rationale: The correct answer is C. DRIs are intended for the general population and do not specifically address disease states, which are managed with different clinical guidelines. Choice A is correct as DRIs have replaced the older recommended daily allowances. Choice B is correct as current DRIs aim to estimate the required nutrients for long-term health. Choice D is correct as DRIs also attempt to establish maximum safe levels of tolerance for nutrients.
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