Medical Surgical Nursing 2nd Edition By Osborn Wraa Watson)

Medical Surgical Nursing 2nd Edition By Osborn Wraa Watson)

Osborn, Medical-Surgical Nursing, 2e
Chapter 08
Question 1
Type: MCSA
During a nutritional assessment, a patient asks why the waist circumference measurement is needed. What is the nurse’s best response?
1. “It helps determine if the BMI is accurate.”
2. “It is more reliable than skinfold measurements.”
3. “It is the only tool that can reliably provide information on nutritional status.”
4. “It helps in determining your risk for cardiovascular disease.”
Correct Answer: 4
Rationale 1: Body mass index (BMI) is used to calculate appropriate weight for height. It is not based on waist circumference.
Rationale 2: Skinfold measurements determine body composition and are not compared to waist measurement for reliability.
Rationale 3: There are numerous tools that are used together to provide information on nutritional status. No one tool works alone.
Rationale 4: Waist circumference is one measurement used to help determine a patient’s risk for the development of cardiovascular disease.
Global Rationale:

Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8-1

Question 2
Type: MCSA
The nurse is conducting a nutrition assessment on a patient who has been admitted for hip replacement surgery. The patient reports that he is Jewish and follows the kosher dietary tradition. Which statement by the nurse will have the greatest impact on the patient’s nutritional health during his hospitalization?
1. “I’ll arrange for a dietitian to come and discuss your food requirements with you.”
2. “Would you be more comfortable with having your family bring you food from home?”
3. “Remember that you will need to increase your protein input postsurgery.”
4. “Please tell me more about your preferred eating habits.”
Correct Answer: 4
Rationale 1: A consultation with a dietician may become necessary, but this is not the best first step. Immediate dietary consultation takes the nurse out of the picture and does not best facilitate nursing care.
Rationale 2: Placing the responsibility to properly nourish the patient on the family is not appropriate because it neglects a vital nursing duty.
Rationale 3: Focusing on protein consumption limits the exchange of information between the patient and the nurse.
Rationale 4: Asking the patient to discuss preferred eating habits and requirements will facilitate meeting the patient’s cultural and religious needs.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8-1

Question 3
Type: MCSA
The nurse is advising a patient who is concerned about the need to lose weight. When discussing daily nutritional requirements, the patient reports hating vegetables. Which statement best reflects the current recommendations appropriate for this patient?
1. “Would you consider drinking a vegetable juice in place of whole vegetables?”
2. “If you want to maintain a healthy weight, eating vegetables will help tremendously.”
3. “Vegetables are generally low in calories and should be incorporated in the daily diet.”
4. “Can you try eating a daily serving of carrots or spinach, either cooked or in a salad?”
Correct Answer: 4
Rationale 1: Suggesting an alternative to whole vegetables does not directly address the patient’s reluctance to eat vegetables.
Rationale 2: Encouraging the consumption of vegetables because they are helpful in weight loss does not directly address the patient’s reluctance to eat vegetables.
Rationale 3: Encouraging the consumption of vegetables because they are low in calories does not directly address the patient’s reluctance to eat vegetables.
Rationale 4: Asking if the patient is willing to eat carrots and/or spinach reflects an understanding of the importance of consuming at least one serving of either dark green or orange vegetables daily. The nurse is offering suggestions regarding common vegetables the patient is more likely to eat.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8-2

Question 4
Type: MCSA
The nurse is reviewing written material on nutrition that is being distributed at a senior citizens center. The nurse recognizes that which statement does not accurately reflect the Dietary Guidelines for Americans, 2010 Edition and should be revised?
1. Half of all grains should be consumed as whole grains.
2. Sodium intake should be less than 1,500 mg daily.
3. Use oils to replace solid fats where possible.
4. Saturated fats should account for no more than 30% of daily calories.
Correct Answer: 4
Rationale 1: These guidelines recommend increasing whole grain intake by replacing refined grains with whole grains. At least half of all grains consumed should be whole grains.
Rationale 2: These guidelines have specific sodium intake recommendations for different populations. Sodium intake for those over 51 (which reflects the population in a senior center) should be no more than 1,500 mg daily.
Rationale 3: These guidelines recommend the use of oils in place of solid fats where possible.
Rationale 4: According to these guidelines, saturated fats should account for no more than 10% of daily calories; this statement should be revised.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8-2

Question 5
Type: MCSA
The nurse is planning care for a postoperative patient who has just resumed a regular diet. What should the nurse include when planning for this patient’s nutritional needs?
1. Protein intake should be restricted.
2. Calories should be limited because of reduced activity.
3. Carbohydrate intake should be restricted.
4. Daily caloric intake should be increased.
Correct Answer: 4
Rationale 1: Protein should not be restricted during times of physiological stress.
Rationale 2: Calories should not be limited during times of physiological stress.
Rationale 3: Carbohydrates should not be restricted during times of physiological stress.
Rationale 4: Major surgery is considered a physiological stress. Physiological stress can lead to hypermetabolism (increase in resting energy needs) as well as hypercatabolism (breakdown of skeletal muscle to meet the body’s energy needs). Calories, protein, and carbohydrates should not be restricted.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8-4

Question 6
Type: MCSA
The nurse is caring for a patient receiving an extensive regimen of chemotherapy. The nurse recognizes that the patient’s ability to avoid muscle wasting during this treatment is most affected by which factor?
1. Pretreatment nutritional status
2. Management of nausea and vomiting
3. General attitude related to food
4. Nutritional value of the foods the patient is likely to eat
Correct Answer: 1
Rationale 1: The patient who is already malnourished before surgery, injury, or disease will have less available body stores to draw on during a metabolically challenging event.
Rationale 2: The management of nausea and vomiting is not specific to muscle wasting.
Rationale 3: This factor applies to all patients and is not specific to muscle wasting.
Rationale 4: This factor applies to all patients and is not specific to muscle wasting.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8-3

Question 7
Type: MCMA
The nurse is providing care to a patient in the burn unit. What should the nurse do to ensure an adequate nutritional status for this patient?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Plan for a parenteral nutrition access site.
2. Ensure that 5 g/kg of protein are provided daily.
3. Keep the patient NPO.
4. Report daily weights to avoid a weight loss of >10%.
5. Ensure the patient receives a minimum of 35 to 40 calories/kg of body weight each day.
Correct Answer: 4,5
Rationale 1: Enteral feedings are recommended for burn patients because of the risk of infection.
Rationale 2: Protein intake of 1.5 g/kg of body weight is recommended for tissue repair.
Rationale 3: The patient should receive early oral or enteral feedings.
Rationale 4: Daily weights are monitored to assess for weight loss. A weight loss of >10% impairs the healing process.
Rationale 5: Typically 35 to 40 calories/kg per day are required for adults. This may be adjusted for the energy expended as burns heal.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8-4

Question 8
Type: MCSA
The nurse is caring for a patient recovering from a total hip replacement. Which nutritional intervention is indicated?
1. Assess for tolerance to diet and progress from clear liquid to another level as tolerated.
2. Maintain a clear liquid diet with intravenous fluid supplementation.
3. Plan to support nutritional status with parenteral supplements.
4. Plan to support nutritional status with enteral feedings.
Correct Answer: 1
Rationale 1: The patient should be transitioned to an oral diet or enteral feedings as quickly as possible.
Rationale 2: Prolonged NPO status, peripheral intravenous fluids, or extensive use of clear liquids is not sufficient to support nutritional needs.
Rationale 3: There is no evidence to suggest that the patient will need parenteral supplementation.
Rationale 4: There is no evidence to suggest that the patient will need enteral feedings.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8-4

Question 9
Type: MCMA
A patient is postoperative from kidney transplant. What nutritional care is appropriate for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Begin the introduction of previously restricted foods.
2. Meet the demands of any existing hypermetabolic process.
3. Correct any preexisting deficiencies.
4. Provide necessary support to promote wound healing.
5. Restrict calories to prevent the postoperative weight gain common with this procedure.
Correct Answer: 1,2,3,4
Rationale 1: Patients undergoing renal or hepatic transplantation may have been on a restrictive diet that may be liberalized following surgery when organ function improves.
Rationale 2: This patient’s postoperative recovery requires adequate nutrition to support the hypermetabolic demands of the surgery.
Rationale 3: This patient may have been maintained on a very restrictive diet that resulted in nutritional deficiencies. These deficiencies should be addressed postoperatively as kidney function improves.
Rationale 4: Adequate nutrition for wound healing is an essential component of postoperative care.
Rationale 5: Postoperative weight gain may be desirable for these patients, depending on their presurgical weight. Calories are necessary for healing and would not be restricted.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8-5

Question 10
Type: MCSA
The nurse is planning care for a patient with liver cirrhosis and resultant ascites. What intervention should be included to ensure an adequate nutritional status for this patient?
1. Ensure caloric intake of 10 to 15 calories per kg of body weight.
2. Provide small, more frequent, high-protein meals.
3. Encourage foods higher in sodium.
4. Implement a very low-fat diet.
Correct Answer: 2
Rationale 1: Calorie needs can vary but are estimated to be between 35 to 40 calories per kg of body weight.
Rationale 2: Nutrition therapy in cirrhosis cases should include adequate protein intake to support hepatic regeneration.
Rationale 3: Because ascites is present it is more likely that sodium will be restricted.
Rationale 4: Patients with cirrhosis may already have fat absorption deficiency due to pancreatic exocrine insufficiency. Fat is essential for the absorption of vitamins. A very low-fat diet is not indicated for this patient.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8-5

Question 11
Type: MCSA
A patient is admitted for treatment of celiac sprue. Which nursing intervention is indicated to address this patient’s nutritional needs?
1. Instruct the patient to consume products identified as “new and improved.”
2. Encourage the patient to try an oral lactase enzyme product.
3. Limit iron and B vitamin intake.
4. Identify gluten-containing foods and eliminate them from the diet.
Correct Answer: 4
Rationale 1: Food products labeled as “new and improved” should be studied for the contents, as they might contain ingredients this patient should avoid.
Rationale 2: Oral lactase enzyme products are a digestive aid often recommended for patients with lactose intolerance, not celiac sprue.
Rationale 3: Because of this patient’s dietary restrictions, iron and vitamin B deficiencies may occur. The patient should be encouraged to seek alternative sources of iron and vitamin B.
Rationale 4: Celiac sprue is a lifelong condition in which the villi in the small intestines are damaged from gluten in the diet. Gluten-containing foods must be eliminated from the diet to avoid disease symptoms.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 8-5

Question 12
Type: MCSA
A patient with a nasogastric tube for intermittent enteral feedings has been coughing. Which intervention should the nurse perform prior to using the tube?
1. Reassess for tube placement.
2. Give the next feeding more slowly.
3. Flush the tube with sterile water prior to giving the next feeding.
4. Place the head of the bed at a 10-degree angle.
Correct Answer: 1
Rationale 1: Severe coughing can lead to nasal tube displacement. The tube placement should be reassessed before using.
Rationale 2: The nurse should not introduce feeding until another action has been performed.
Rationale 3: The nurse should not introduce fluid into the tube until another action has been performed.
Rationale 4: The head of the bed should be placed at a 30- to 45-degree angle to reduce the risk of aspiration.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8-6

Question 13
Type: MCSA
A patient is being weaned from parenteral nutrition. Which intervention would support the weaning process?
1. Discontinue parenteral nutrition and begin enteral nutrition.
2. Reduce the rate according to protocol.
3. Discontinue the nutrition and provide regular meals.
4. Discontinue parenteral nutrition and begin peripheral nutrition with dextrose 20%.
Correct Answer: 2
Rationale 1: Parenteral nutrition should not be discontinued without assessing the patient’s tolerance for a diet or enteral nutrition.
Rationale 2: Weaning should be conducted according to the organization’s protocol. A patient can be weaned from parenteral nutrition by either reducing the amount administered per hour or by substituting with a high-dextrose solution administered peripherally.
Rationale 3: Parenteral nutrition should not be discontinued without assessing the patient’s tolerance for a diet or enteral nutrition.
Rationale 4: Solutions higher than 10% dextrose are hypertonic and cannot be administered peripherally.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8-6

Question 14
Type: MCSA
A patient receiving enteral feeding via a nasogastric tube (NG) has also been prescribed several medications. What is the nurse’s initial intervention?
1. Confirm that there are no incompatibility issues between the medications and the enteral formula.
2. Flush the NG tube before, between, and after medication delivery.
3. Determine whether this administration route is appropriate for the prescribed medications.
4. Keep the head of the patient’s bed at a 45-degree angle during and immediately after medication delivery.
Correct Answer: 3
Rationale 1: This assessment is important but is not the initial intervention.
Rationale 2: The nurse should flush the tube before, between, and after medication delivery, but this is not the initial intervention.
Rationale 3: Determining whether this administration route is appropriate for the prescribed medications is the correct initial intervention; many but not all medications may be administered via the NG route.
Rationale 4: The head of the patient’s bed should be placed at a 30- to 45-degree angle prior to and immediately after medication delivery, but this is not the initial intervention.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8-6

Question 15
Type: MCMA
The nurse is caring for an elderly patient who recently experienced a cerebral vascular accident (CVA, or stroke). The nurse will evaluate which assessment findings as indicating dysphagia?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Drooling
2. Slurred speech
3. Pocketing of food in the cheeks
4. Anorexia
5. Frequent throat clearing
Correct Answer: 1,3,5
Rationale 1: When a patient is at risk for dysphagia, the nurse would evaluate for such findings as drooling.
Rationale 2: Slurring of speech is more likely to be associated with the effects of CVA and is not indicative of dysphagia.
Rationale 3: Pocketing of food in the cheeks is typically associated with dysphagia.
Rationale 4: Dysphagia interrupts the patient’s ability to eat and would more likely result in hunger than in anorexia.
Rationale 5: Frequent throat clearing, especially during eating, is typically associated with dysphagia.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8-7

Question 16
Type: MCMA
According to BMI measurements, a patient is overweight. Which additional assessments would the nurse perform to verify this conclusion?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Wrist circumference
2. Length of femur
3. Head circumference
4. Elbow breadth
5. Maximum length from tip of thumb to tip of small finger
Correct Answer: 1,4
Rationale 1: Wrist circumference is related to bone structure. The BMI measurement tends to classify patients with large bone structure as overweight even when they are not.
Rationale 2: The length of the femur does not add information regarding the accuracy of BMI interpretation.
Rationale 3: Head circumference does not add information regarding the accuracy of BMI interpretation.
Rationale 4: The breadth of the elbow is related to bone structure. BMI measurement tends to classify patients with large bone structure as overweight even when they are not.
Rationale 5: Measuring the maximum spread of the hand does not add information regarding the accuracy of BMI interpretation.
Global Rationale:

Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8-1

Question 17
Type: MCMA
The mother of a 14-year-old boy is concerned that her son may have anorexia nervosa. Which statements by the mother would the nurse evaluate as supporting this concern?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. “His whole focus in life is on improving his marathon time.”
2. “He complains of being hot all the time.”
3. “He is losing his hair.”
4. “He has lost 5 pounds since he started football practice.”
5. “He seems so skinny and weak.”
Correct Answer: 1,3,5
Rationale 1: Distance runners can be at risk for anorexia nervosa because of the performance thinness philosophy associated with the sport.
Rationale 2: The more frequent complaint with anorexia nervosa is of being cold all the time.
Rationale 3: Alopecia is a common result of anorexia nervosa.
Rationale 4: Weight loss from exercise is not in itself an indicator of anorexia nervosa.
Rationale 5: Loss of muscle mass and weakness can result from anorexia nervosa. The nurse would also assess for other diseases or disorders.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8-7

Question 18
Type: MCMA
An elderly patient is admitted after being found alone in the home with no food available. Severe malnutrition is diagnosed and refeeding has been instituted. The nurse should plan to monitor this patient for which complications of this therapy?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Hypernatremia
2. Low potassium levels
3. Prolongation of the PR interval
4. Edema
5. Pulmonary crackles
Correct Answer: 2,4,5
Rationale 1: High sodium levels are not a complication of refeeding.
Rationale 2: Potassium stores are depleted as new ATP is generated. This is a serious adverse effect of refeeding.
Rationale 3: The most common finding is prolongation of the QT interval, not prolongation of the PR interval.
Rationale 4: Edema may be caused by other factors but is also associated with refeeding.
Rationale 5: The patient may develop heart failure, which would be evidenced by the presence of crackles.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 8-5

Question 19
Type: MCSA
The nurse has been providing nutritional education to a patient. Which statement would indicate the patient understands the information regarding low-sodium foods?
1. “I should look for foods with ‘reduced sodium’ on the label.”
2. “I should purchase canned vegetables.”
3. “I should avoid foods whose labels indicate they are smoked or cured.”
4. “Most fruit juices are naturally high in sodium.”
Correct Answer: 3
Rationale 1: The term “reduced sodium” means that the product has 25% less sodium than the original form. It does not mean the food is low in sodium.
Rationale 2: Canned vegetables generally have more sodium than their fresh or frozen counterparts.
Rationale 3: The words “smoked” or “cured” are hints that the food is high in sodium.
Rationale 4: Fresh fruit and fruit juices are naturally low in sodium.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 8-7

Question 20
Type: MCSA
A patient who has just been diagnosed with type 2 diabetes asks, “Is it okay for me to have an occasional glass of beer?” What is the nurse’s best advice?
1. “I’m so sorry but you should not drink any alcohol.”
2. “As long as you are not drinking to excess, beer will have no effect on your blood glucose.”
3. “An occasional beer is fine as long as you eat something while you are drinking it.”
4. “You can drink a beer if you eliminate other foods from your diet that day.”
Correct Answer: 3
Rationale 1: The recommendations for alcohol intake for patients with diabetes closely coincide with those for the general adult population.
Rationale 2: The alcohol in beer affects blood glucose.
Rationale 3: People with diabetes should be aware of the potential hypoglycemic and hyperglycemic effects of alcohol and consume it along with food.
Rationale 4: The nurse should not encourage the patient to eliminate food so that alcohol can be consumed.
Global Rationale:

Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 8-5