Chapter 4: Adult Health and Physical, Nutritional, and Cultural As-

sessment

1. A school nurse is teaching a 14-year-old girl of normal weight some of the key
factors necessary to maintain good nutrition in this stage of growth and development.
What interventions should the nurse prioritize to the client?
A. Decreasing her calorie intake and encouraging her to maintain her weight to
avoid obesity
B. Increasing her BMI, taking a multivitamin, and discussing body image
C. Increasing calcium intake, eating a balanced diet, and discussing eating
disorders
D. Obtaining a food diary along with providing close monitoring for anorexia

ANS: C

Rationale: Adolescent girls are considered to be at high risk for nutritional disorders.
Increasing calcium intake and promoting a balanced diet will provide the necessary
vitamins and minerals. If adolescents are diagnosed with eating disorders early, they
have a better chance of recovery. The question presents no information that indicates
a need for decreasing the client’s calories. There is no apparent need for an increase in
BMI. A food diary is used for assessing eating habits, but the question asks for
teaching factors related to good nutrition.

PTS: 1 REF: p. 86 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

2. The nurse is performing an admission assessment of a client with minimal

understanding of the dominant language. An interpreter who speaks the client's
language is unavailable and no members of the care team speak the language. How
will the nurse best perform data collection?
A. Have a family member provide the data.
 B. Obtain the data from the old chart and health care provider's assessment.
C. Obtain the data only from the client.
D. Collect all possible data from the client and wait for a health facility
interpreter.

ANS: D

Rationale: The nurse should collect as much data as possible from the client and then
complete the data collection once the interpreter arrives. Having family provide any
missing details may violate privacy. The old chart may not contain information needed
for the current admission and may not be a complete record of the client’s health
history and medications. The health care provider’s assessment may not provide
information needed to provide nursing care, such as religious or cultural
considerations. The nurse should always obtain as much information as possible
directly from the client; however, in this case, it is not possible to get all the
information needed only from the client.

PTS: 1 REF: p. 81
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level:
Apply
NOT: Multiple Choice

3. The nurse is assessing a 28-year-old client who has presented to the emergency
department with vague reports of malaise. The nurse observes bruising to the client's
upper arm that corresponds to the outline of fingers as well as yellow bruising around
the left eye. The client makes minimal eye contact during the assessment. How should
the nurse best inquire about the bruising?
A. "Is anyone physically hurting you?"
B. "Tell me about your relationships."
C. "Do you want to see a social worker?"
D. "Is there something you want to tell me?"

ANS: A
Rationale: Few clients will discuss the topic of violence unless they are directly asked.
Therefore, it is important to ask direct questions, such as, "Is anyone physically
hurting you?" The other options are incorrect because they are not the best way to
elicit information about possible violence in a direct and appropriate manner.

PTS: 1 REF: p. 82 NAT: Client Needs: Psychosocial Integrity

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level:
Apply
NOT: Multiple Choice

4. The nurse is taking a health history on an adult client who is new to the clinic. The
client states that the client’s mother has type 1 diabetes. What is the primary
significance of this information to the health history?
A. The client may be at risk for developing diabetes.
B. The client may need teaching on the effects of diabetes.
C. The client may need to attend a support group for individuals with diabetes.
D. The client may benefit from a dietary regimen that tracks glucose intake.

ANS: A

Rationale: Nurses incorporate a genetic focus into the health assessments of family
history to assess for genetics-related risk factors. The information aids the nurse in
determining whether the client may be predisposed to diseases that are genetic in
origin. The results of diabetes testing would determine whether dietary changes,
support groups or health education would be needed.

PTS: 1 REF: p. 75 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Communication and Documentation BLM: Cognitive Level:
Apply
NOT: Multiple Choice
5. A nurse is performing the admission assessment of a client who will be treated for
pancreatitis on the medical unit. During the nursing assessment, the nurse asks the
client questions related to the client’s spirituality. The primary rationale for this aspect
of the nurse's assessment is that the client’s spiritual environment can affect which
area of life?
A. Physical activity
B. Ability to communicate
C. Quality of sexual relationships
D. Response to illness

ANS: D

Rationale: Illness may cause a spiritual crisis and can place considerable stresses on a
person's internal resources. The term spiritual environment refers to the degree to
which a person has contemplated their own existence. The other listed options may be
right, but they are not the most important reasons for a nurse to assess a client's
spiritual environment, which is directly related to health.

PTS: 1 REF: p. 79 NAT: Client Needs: Psychosocial Integrity

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice

6. The school nurse is working with a high school junior whose body mass index (BMI)
is 31. When working collaboratively with the client on the care plan, the nurse should
propose which goal?
A. Continuation of current diet and activity level
B. Increase in exercise and reduction in calorie intake
C. Possible referral to an eating disorder clinic
D. Increase in daily calorie intake

ANS: B

Rationale: A BMI of 31 is considered clinically obese; dietary and exercise

modifications would be indicated. People who have a BMI lower than 24 (or who are
80% or less of their desirable body weight for height) are at increased risk for
problems associated with poor nutritional status. Those who have a BMI of 25 to 29.9
are considered overweight; those with a BMI of 30 or greater are considered to be
obese.

PTS: 1 REF: p. 88
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

7. A home care nurse is teaching meal planning to a client's adult child who is caring
for the client during recovery from hip replacement surgery. Which daily menus
suggested by the client’s child indicates a correct understanding of proper nutrition,
based on the U.S. Department of Agriculture's MyPlate?
A. Cheeseburger, carrot sticks, and mushroom soup with whole wheat crackers
B. Spaghetti and meat sauce with garlic bread and a salad
C. Chicken and pepper stir fry on a bed of rice
D. Ham sandwich with tomato on rye bread with peaches and yogurt

ANS: D

Rationale: This menu has a choice from each of the food groups identified in MyPlate:
grains, vegetables, fruits, dairy, and protein. The other selections are incomplete
choices.

PTS: 1 REF: p. 91 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

8. The nurse is assessing a 76-year-old client who has presented with an unintended
weight loss of 10 lb over the past 8 weeks. During the assessment, the nurse learns
that the client has ill-fitting dentures and a limited intake of high-fiber foods. What
other health problem is the client at risk to develop?
 A. Constipation
B. Deficient fluid volume
C. Infection
D. Excessive intake of convenience foods

ANS: A

Rationale: Clients with ill-fitting dentures are at a potential risk for an inadequate
intake of high-fiber foods. Older adults are already at an increased risk for constipation
because of other developmental factors and the potential for a decreased activity level.
Ill-fitting dentures do not put a client at risk for dehydration, infection, or a reliance on
convenience foods.

PTS: 1 REF: p. 92
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

9. The nurse is teaching a nutrition education class for a group of older adults at a
senior center. When planning this education, the nurse should be aware that
individuals at this point in the lifespan have which of the following?
A. A decreased need for calcium
B. An increased need for glucose
C. An increased need for sodium
D. A decreased need for calories

ANS: D

Rationale: The older adult has a decreased metabolism, and absorption of nutrients
has decreased. The older adult has an increased need for sound nutrition but a
decreased need for calories. The other options are incorrect because there is no
decreased need for calcium and no increased need for either glucose or sodium.

PTS: 1 REF: p. 86 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Understand
NOT: Multiple Choice

10. The emergency department nurse is obtaining a health history from a client who
reported experiencing intermittent abdominal pain. Which question should the nurse
ask to elicit the probable reason for the visit and identify the client’s chief issue?
A. "Why do you think your abdomen is painful?"
B. "Where exactly is your abdominal pain and when did it start?"
C. "What brings you to the hospital today?"
D. "What is wrong with you today?"

ANS: C

Rationale: The chief client issue should clearly address what has brought the client to
see the health care provider; an open-ended question best serves this purpose. The
question "What brings you to the hospital?" allows the client sufficient latitude to
provide an answer that expresses the priority issue. Focusing solely on abdominal pain
would be too specific to serve as the first question regarding the chief client issue.
Asking, "What is wrong with you today?" is an open-ended question but still directs the
client toward the fact that there is a problem.

PTS: 1 REF: p. 76
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

11. The nurse is caring for a client who identifies as Native American/First Nations. The
client arrives at the clinic for treatment related to type 2 diabetes. Which question
would best provide information about the role of food in the client's cultural practices
and identify how the client's food preferences could be related to the current condition?
A. "Do you feel any of your cultural practices have a negative impact on your
disease process?"
 B. "What types of foods are served as a part of your cultural practices, and how
are they prepared?"
C. "As a non-Native, I am unaware of your cultural practices. Could you teach
me a few practices that may affect your care?"
D. "Tell me about foods that you eat and how you feel they influence managing
your diabetes."

ANS: D

Rationale: While the beliefs and practices that have been shared from generation to
generation are known as cultural or ethnic patterns, the nurse should not assume that
the client follows these practices. Rather, the nurse should ask what foods the client
eats and how the client feels those foods affect diabetes management. An
overemphasis on negatives can inhibit assessment and communication. Assessing the
types and preparation of foods specific to cultural practices without relating it to
diabetes is inadequate. The question, "As a non-Native, I am unaware of your cultural
practices. Could you teach me a few practices that may affect your care?" focuses on
"care" and fails to address the significance of food in cultural practice or diabetes.

PTS: 1 REF: p. 79 NAT: Client Needs: Psychosocial Integrity

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply
NOT: Multiple Choice

12. A 30-year-old client is in the clinic for a yearly physical. The client states, "I found
out that two of my uncles had heart attacks when they were young." This alerts the
nurse to complete a genetic-specific assessment. In addition to a complete health
history, which components should the nurse include in this assessment?
A. A genogram along with any history of cholesterol testing or screening and a
complete physical exam
B. A complete physical exam with an emphasis on genetic abnormalities
C. A focused physical exam followed by safety-related education
D. A family history focused on the paternal family with focused physical exam
and genetic profile
ANS: A

Rationale: A genetic-specific exam in this case would include a complete health history,
genogram, a history of cholesterol testing or screening, and a complete physical exam.
A complete, not focused, physical examination is warranted and safety education is not
directly relevant. A full genogram is needed, not just a family history focused on the
paternal family.

PTS: 1 REF: p. 76 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

13. The school nurse is performing a sports physical on a healthy adolescent girl who is
planning to try out for the volleyball team. When it comes time to listen to the
student's heart and lungs, what is the best nursing action?
A. Perform auscultation with the stethoscope placed firmly over the clothing to
protect the client’s privacy.
B. Perform auscultation by holding the diaphragm lightly on the client’s clothing
to eliminate the "scratchy noise".
C. Perform auscultation with the diaphragm placed firmly on the client’s skin to
minimize extra noise.
D. Defer the exam because the girl is known to be healthy and chest auscultation
may cause anxiety.

ANS: C

Rationale: Auscultation should always be performed with the diaphragm placed firmly
on the skin to minimize extra noise and with the bell lightly placed on the skin to
reduce distortion caused by vibration. Placing a stethoscope over clothing limits the
conduction of sound. Performing auscultation is an important part of a sports physical
and should never be deferred.

PTS: 1 REF: p. 85
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

14. A nurse who provides care in a campus medical clinic is performing an assessment
of a 21-year-old student who has presented for care. After assessment, the nurse
determines that the client has a body mass index (BMI) of 45. What does this indicate?
A. The client is of normal weight.
B. The client is extremely obese.
C. The client is overweight.
D. The client is mildly obese.

ANS: B

Rationale: Individuals who have a BMI between 25 and 29.9 are considered
overweight. Obesity is defined as a BMI of greater than 30. A BMI of 45 would indicate
extreme obesity.

PTS: 1 REF: p. 88
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice

15. A nurse is conducting a home visit as part of the community health assessment of
a client who will receive scheduled wound care. During assessment, the nurse should
prioritize what variable(s)?
A. Availability of home health care, current government subsidies, and family
support
B. The community and home environment, support systems or family care, and
the availability of needed resources
C. The future health status of the individual, and community and hospital
resources
D. The characteristics of the neighborhood, and the client's socioeconomic status
and insurance coverage
ANS: B

Rationale: The community or home environment, support systems or family care, and
the availability of needed resources are the key factors that distinguish community
assessment from assessments in the acute care setting. The other options fail to
address the specifics of either the community or the actual home environment.

PTS: 1 REF: p. 73
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

16. The nurse is performing a health history on a client. Which question will the nurse
ask to elicit information about past health history?
A. “Have you ever had surgery?”
B. “What brought you to the hospital today?”
C. “How is the health of your parents?”
D. “Are you in any pain?”

ANS: A

Rationale: Asking the client about health history elicits information about
immunizations, allergies, surgeries, and illnesses. Asking why the client is seeking
health care today is addressing a present health concern. Asking about the health of
the client’s parents is addressing family history. Asking about pain is also addressing
the present health concern.

PTS: 1 REF: p. 73
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
17. The nurse is admitting a 75-year-old client who is accompanied by a spouse. The
spouse wants to know where the information being obtained is going to be kept, and
the nurse describes the system of electronic health records. The spouse states, "I sure
am not comfortable with that. It is too easy for someone to break into computer
records these days." What is the nurse’s best response?
A. "The government has called for the implementation of the computerized
health record so all hospitals are doing it."
B. "We've been doing this for several years with good success, so I can assure
you that our records are very safe."
C. "This hospital is concerned about keeping our clients' records private, so we
take special precautions to prevent unauthorized access."
D. "Your spouse's records will be safe, because only people who work in the
hospital have the credentials to access them."

ANS: C

Rationale: Nurses must be sensitive to the needs of older adults and others who may
not be comfortable with computer technology. Special precautions are indeed taken.
Not every hospital employee has access and referencing the government may not
provide reassurance.

PTS: 1 REF: p. 73
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply
NOT: Multiple Choice

18. A family whose religion limits the use of some forms of technology is admitting
their grandparent to the nurse's unit. They express skepticism about the fact that the
nurse is recording the admission data on a laptop computer. What would be the
nurse's best response to their concerns?
A. "It's been found that using computers improves our clients' care and improves
communication."
B. "We have found that it is easier to keep track of our clients' information this
way rather than with pen and paper."
 C. "You'll find that all the hospitals are doing this now, and that writing
information with a pen is rare."
D. "The government is telling us we have to do this, even though most people,
like yourselves, are opposed to it."

ANS: A

Rationale: EHRs enable clear communication among care team members and the
collection of data for continuous improvement in client care. Electronic documentation
is not always easier and most people are not opposed to it. Stating that all hospitals do
this does not directly address their reluctance or state the benefits. The use of
technology in health care settings is not specifically mandated by legislation.

PTS: 1 REF: p. 72
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Teaching/Learning BLM: Cognitive Level: Apply
NOT: Multiple Choice

19. The nurse is performing a dietary assessment with a client who has been admitted
to the medical unit with community-acquired pneumonia. The client asks if the nurse is
posing so many questions about the client’s dietary practices because the client is from
another country. What is the nurse's best response to this client?
A. "We always try to abide by foreign-born clients' dietary preferences to make
them comfortable."
B. "We know that some cultural and religious practices include dietary guidelines,
and we do not want to violate these."
C. "We wouldn't want to feed you anything you only eat on certain holidays."
D. "We know that clients who grew up in other countries often have unusual
diets, and we want to accommodate this."

ANS: B
Rationale: Culture and religious practices together often determine whether certain
foods are prohibited and whether certain foods and spices are eaten on certain
holidays or at specific family gatherings. A specific focus on holidays, however, does
not convey the overall intent of the dietary interview. Dietary planning addresses all
clients' needs, not only those who are immigrants. It is inappropriate to characterize a
client's diet as "unusual."

PTS: 1 REF: p. 73 NAT: Client Needs: Psychosocial Integrity

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply
NOT: Multiple Choice

20. In the course of performing an admission assessment, the nurse has asked
questions about the client's first- and second-order relatives. What is the primary
rationale for the nurse's line of questioning?
A. To determine how many living relatives the client has
B. To identify the family's level of health literacy
C. To identify potential sources of social support
D. To identify diseases that may be genetic

ANS: D

Rationale: To identify diseases that may be genetic, communicable, or possibly

environmental in origin, the interviewer asks about the age and health status, or the
age and cause of death, of first-order relatives (parents, siblings, spouse, children) and
second-order relatives (grandparents, cousins). This is a priority over the number of
living relatives, sources of support, or health literacy, though each of these may be
relevant.

PTS: 1 REF: p. 75
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
21. The nurse is completing a family history for a client who is admitted for
exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should
include questions that address which health problem? Select all that apply.
A. Allergies
B. Alcohol use disorder
C. Fractures
D. Hypervitaminosis
E. Obesity

ANS: A, B, E

Rationale: In general, the following conditions are included in a family history: cancer,
hypertension, heart disease, diabetes, epilepsy, mental illness, tuberculosis, kidney
disease, arthritis, allergies, asthma, alcohol use disorder, and obesity. Fractures and
hypervitaminosis do not have genetic etiologies.

PTS: 1 REF: p. 75
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Response

22. Which action would the nurse perform during the inspection phase of the physical
examination?
A. Gather as many psychosocial details as possible by questioning the client.
B. Pay attention to the details while visually observing the client.
C. Document the client’s breath sounds.
D. Avoid letting the client know that the client is being assessed.

ANS: B

Rationale: During inspection, it is essential for the nurse to pay attention to the details
while visually observing the client. Gathering psychosocial details by questioning the
client would occur during the health history, not during inspection (visual observation)
or any other phase of the physical examination. Documenting the client’s breath
sounds would occur during auscultation (assessment by listening to body sounds with a
stethoscope), not during inspection. It is not necessary avoid letting the client know
that the client is being assessed.

PTS: 1 REF: p. 84
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

23. During a comprehensive health assessment, which structure can the nurse best
assess by palpation?
A. Brain
B. Heart
C. Thyroid gland
D. Lungs

ANS: C

Rationale: Many structures of the body, although not visible, may be assessed through
the techniques of light and deep palpation. Examples include the superficial blood
vessels, lymph nodes, thyroid gland, organs of the abdomen and pelvis, and rectum.
The brain, encased within the skull, and the heart and lungs, located behind the ribs,
are not accessible to palpation and are typically assessed via other methods (i.e.,
imaging, electroencephalograph, echocardiography).

PTS: 1 REF: p. 84
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice

24. A 51-year-old client’s recent reports of fatigue are thought to be caused by iron-
deficiency anemia. The client undergoes testing of the transferrin levels. This
biochemical assessment would be performed by assessing which type of specimen?
 A. Urine
B. Serum
C. Cerebrospinal fluid (CSF)
D. Synovial fluid

ANS: B

Rationale: Biochemical assessments are made from studies of serum (albumin,

transferrin, retinol-binding protein, electrolytes, hemoglobin, vitamin A, carotene,
vitamin C, and total lymphocyte count) and studies of urine (creatinine, thiamine,
riboflavin, niacin, and iodine). Transferrin is found in serum, not urine, CSF, or synovial
fluid.

PTS: 1 REF: p. 88
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice

25. A school nurse at a middle school is planning a health promotion initiative for girls.
The nurse has identified a need for nutritional teaching. What problem is most likely to
relate to nutritional problems in girls of this age?
A. Protein intake in this age group often falls below recommended levels.
B. Total calorie intake is often insufficient at this age.
C. Calcium intake is above the recommended levels.
D. Folate intake is below the recommended levels in this age group.

ANS: D

Rationale: Adolescent girls are at particular nutritional risk, because iron, folate, and
calcium intakes are below recommended levels, and they are a less physically active
group compared to adolescent males. Protein and calorie intakes are most often
sufficient.

PTS: 1 REF: p. 86 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

26. A team of community health nurses has partnered with the staff at a youth drop-in
center to address some of the nutritional needs of adolescents. Which situation most
often occurs during the adolescent years?
A. Lifelong eating habits are acquired.
B. Peer pressure influences growth.
C. BMI is determined.
D. Culture begins to influence diet.

ANS: A

Rationale: Adolescence is a time of critical growth and acquisition of lifelong eating

habits; therefore, nutritional assessment, analysis, and intervention are critical. Peer
pressure does not influence growth. Cultural influences tend to become less important
during the teen years; they do not emerge for the first time at this age. BMI can be
assessed at any age.

PTS: 1 REF: p. 86 NAT: Client Needs: Health Promotion and Maintenance

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice

27. A nurse who has practiced in the hospital setting for several years will now
transition to a new role in the community. How does a physical assessment in the
community compare with that in the hospital?
A. It consists of largely the same techniques.
B. It does not require privacy.
C. It is less comfortable for the client.
D. It is less structured.

ANS: A
Rationale: The physical assessment in the community and home consists of the same
techniques used in the hospital, outpatient clinic, or office setting. Privacy is provided,
and the person is made as comfortable as possible. The importance of comfort,
privacy, and structure is similar in both settings.

PTS: 1 REF: p. 73
NAT: Client Needs: Physiological Integrity: Basic Care and Comfort
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice

28. The nurse is conducting an assessment of a client in the client’s home. The client is
91 years old, lives alone, and has no family members living close by. What should the
nurse be aware of to aid in providing care to this client?
A. Where the closest relative lives
B. What resources are available to the client
C. What the client's financial status is
D. How many children the client has

ANS: B
Rationale: The nurse must be aware of resources available in the community and
methods of obtaining those resources for the client. The other data would be nice to
know, but are not prerequisites to providing care to this client.

PTS: 1 REF: p. 73
NAT: Client Needs: Physiological Integrity: Basic Care and Comfort
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

29. What is the nurse's rationale for prioritizing biochemical assessment when
appraising a client's nutritional status?
A. It identifies abnormalities in the chemical structure of nutrients.
B. It predicts abnormal utilization of nutrients.
C. It reflects the tissue level of a given nutrient.
 D. It predicts metabolic abnormalities in nutritional intake.

ANS: C

Rationale: Biochemical assessment reflects both the tissue level of a given nutrient and
any abnormality of metabolism in the utilization of nutrients. It does not focus on
abnormalities in the chemical structure of nutrients. Biochemical assessment is not
predictive.

PTS: 1 REF: p. 88
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Apply
NOT: Multiple Choice

30. The nurse is providing care for a client who has several missing teeth. What is the
most likely nutritional consequence the nurse should anticipate for this client?
A. Inadequate intake of high-fiber foods
B. Inadequate caloric intake
C. Loss of fluid
D. Malabsorption of nutrients

ANS: A

Rationale: The most likely nutritional consequence for a client with several missing
teeth is inadequate intake of high-fiber foods. Inadequate caloric intake, loss of fluid,
and malabsorption would be less likely consequences.

PTS: 1 REF: p. 92
NAT: Client Needs: Physiological Integrity: Basic Care and Comfort
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Nursing Process BLM: Cognitive Level: Understand
NOT: Multiple Choice
31. When caring for a client who predominantly identifies with another culture than the
nurse, how can the nurse best demonstrate an awareness of culturally congruent
care?
A. Maintain eye contact at all times.
B. Try to speak the client's primary language.
C. Use touch when communicating.
D. Establish effective communication.

ANS: D

Rationale: Establishment of an environment of culturally congruent care and respect

begins with effective communication, which occurs not only through words, but also
through body language and other cues, such as voice, tone, and loudness. Not all
cultures are comfortable with eye contact. Unless the nurse is fluent in the client's
primary language, trying to communicate in that language would not be effective
communication. Not all cultures incorporate touch while communicating.

PTS: 1 REF: p. 94
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply
NOT: Multiple Choice

32. The nurse is preparing a discharge teaching session with a client to evaluate the
client's ability to change a dressing. The client speaks and understands the dominant
language only minimally. What would be the best way to promote understanding
during the teaching session?
A. Ask the client to repeat the instructions carefully.
B. Write the procedure out for the client in simple language.
C. Use an interpreter during the teaching session.
D. Have the client demonstrate the dressing change.

ANS: C
Rationale: Policies that promote culturally competent care provide translation services
for clients with minimal ability in the dominant language. Writing instructions and
asking the client to repeat instructions do not adequately compensate for the
communication barrier that exists. Having the client demonstrate the procedure would
demonstrate competency but does not address promoting understanding during a
teaching session.

PTS: 1 REF: p. 81
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply
NOT: Multiple Choice

33. The nurse is admitting a client with uncontrolled hypertension and type 1 diabetes
to the unit. During the initial assessment, the client reports seeking assistance and
care from the shaman in the client’s community. What is the nurse's best response to
the client's indication that the care provider is a shaman?
A. "Thank you for providing the information about the shaman, but we will keep
that information and approach separate from your current hospitalization."
B. "It seems that the care provided by your shaman is not adequately managing
your hypertension and diabetes, so we will try researched medical approaches."
C. "Don't worry about insulting your shaman; the health care provider will
explain to the shaman that the shaman’s approach to your hypertension and
diabetes was not working."
D. "I understand that you value the care provided by the shaman, but we would
like you to consider medications and dietary changes that may lower your blood
pressure and blood sugar levels."

ANS: D

Rationale: Some clients may seek assistance from a shaman or medicine man or
woman. The nurse's best approach is not to disregard the client's belief in these
healers or try to undermine trust in these healers. Nurses should make an effort to
accommodate the client's beliefs while also advocating the treatment proposed by
health science. The nurse's best response in incorporating these strategies is, "I
understand that you value the care provided by the shaman, but we would like you to
consider medications and dietary changes that may improve your blood pressure and
blood sugar levels."

PTS: 1 REF: p. 93 NAT: Client Needs: Psychosocial Integrity

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply
NOT: Multiple Choice

34. The nurse is performing a cultural nursing assessment of a newly admitted client.
What should the nurse include in the assessment? Select all that apply.
A. Family structure
B. Subgroups
C. Cultural beliefs
D. Health practices
E. Values

ANS: A, C, D, E

Rationale: Cultural nursing assessment refers to a systematic appraisal or examination

of individuals, families, groups, and communities in terms of their cultural beliefs,
values, and practices. Subgroups are not a specific focus of this assessment.

PTS: 1 REF: p. 91 NAT: Client Needs: Psychosocial Integrity

TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Remember
NOT: Multiple Response

35. The quality improvement team at the hospital has recognized the need to better
integrate the principles of transcultural nursing into client care. When explaining the
concept of transcultural nursing to uninitiated nurses, how should the team members
describe it?
A. The comparative analysis of the health benefits and risks of recognizable
ethnic groups
 B. Research-focused practice that focuses on client-centered, culturally
competent nursing
C. A systematic and evidence-based effort to improve health outcomes in clients
who are immigrants
D. Interventions that seek to address language barriers in nursing practice

ANS: B

Rationale: Transcultural nursing, a term sometimes used interchangeably with cross-

cultural, intercultural, or multicultural nursing, refers to research-focused practice that
focuses on client-centered, culturally competent nursing. It is not limited to language
barriers and foreign-born clients. It does not focus solely on health risks and benefits
in ethnic groups.

PTS: 1 REF: p. 72
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Understand
NOT: Multiple Choice

36. During an orientation class, the medical unit's nursing educator is presenting
education on transcultural nursing to a group of newly licensed nurses. What should
the staff educator identify as the underlying focus of transcultural nursing?
A. To enhance the cultural environment of institutions
B. To promote the health of communities
C. To provide culture-specific and culture-universal care
D. To promote the well-being of discrete, marginalized groups

ANS: C

Rationale: The underlying focus of transcultural nursing is to provide culture-specific

and culture-universal care that promotes the well-being or health of individuals,
families, groups, communities, and institutions. It includes, but is not limited to,
institutions, communities, or marginalized groups.
PTS: 1 REF: p. 72
NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client
Needs: Physiological Integrity: Basic Care and Comfort
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Understand
NOT: Multiple Choice

37. The future of transcultural nursing care lies in finding ways to promote cultural
competence in nursing students. How can this goal be best accomplished?
A. By offering multicultural health studies in nursing curricula
B. By enhancing the content of community nursing classes
C. By requiring students to care primarily for clients from other ethnic groups
D. By screening applicants according to their cultural competence

ANS: A

Rationale: Nursing programs are exploring creative ways to promote cultural

competence and humanistic care in nursing students, including offering multicultural
health studies in their curricula. Enhancing the content of community nursing classes
would not necessarily achieve this goal. Matching students to clients from other
cultures is often impractical, and applicants are not screened by their cultural
competence.

PTS: 1 REF: p. 73
NAT: Client Needs: Psychosocial Integrity | Client Needs: Physiological Integrity: Basic
Care and Comfort
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply
NOT: Multiple Choice

38. Computed tomography of a 72-year-old client reveals lung cancer with metastasis
to the liver. The client's adult child has been adamant that any "bad news" be withheld
from the client to protect the client from stress, stating that this is a priority in their
family’s culture. How should the nurse and the other members of the care team best
respond?
 A. Explain to the adult child the team's ethical obligation to inform the client.
B. Refer the family to social work.
C. Have a nurse or health care provider from the client's culture make contact
with the client and adult child.
D. Speak with the child to explore the rationale and attempt to reach a
consensus.

ANS: D

Rationale: Nurses must promote open dialogue and work with clients, families, health
care providers, and other health care providers to reach the culturally appropriate
solution for the individual client. A referral to social work is not a sufficient response,
and enlisting a caregiver from the same culture may not be ethical or effective.
Although the nurse may need to explain to the client’s child the team’s ethical
obligation to inform the client at some point, the best response is to speak further with
the adult child to explore the rationale and attempt to reach a consensus.

PTS: 1 REF: p. 93
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter 4: Adult Health and Physical, Nutritional, and Cultural Assessment
KEY: Integrated Process: Culture and Spirituality BLM: Cognitive Level: Apply
NOT: Multiple Choice