Which of the following statements about nutritional assessment is true?
It is only useful in patients who are overweight.
It provides the nurse with physical finding related to all the systems.
It identifies patients who are at risk of malnutrition.
Nutritional assessment can only be thoroughly done by a dietitian.
The Correct Answer is C
A. It is only useful in patients who are overweight: Nutritional assessment is valuable for all patients, not just those who are overweight, because it helps identify deficiencies, excesses, or risks in nutrition.
B. It provides the nurse with physical finding related to all the systems: While nutrition affects multiple body systems, the purpose of a nutritional assessment is to evaluate dietary intake, habits, and risk of malnutrition rather than serve as a full systemic physical exam.
C. It identifies patients who are at risk of malnutrition: The primary goal of nutritional assessment is to detect individuals at risk for malnutrition or those already malnourished, guiding early interventions to prevent complications.
D. Nutritional assessment can only be thoroughly done by a dietitian: Nurses are trained to perform nutritional assessments as part of comprehensive patient care, though dietitians may be consulted for more detailed evaluations or complex cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Perform the confrontation test to validate the findings: The confrontation test assesses peripheral vision, not ocular alignment. It would not be the appropriate next step for interpreting a corneal light reflex result.
B. Refer the individual for further evaluation: Referral is necessary if the light reflex is asymmetrical, suggesting strabismus or misalignment. In this case, the reflex is the same in both eyes, so further evaluation is not immediately required.
C. Consider this a normal finding: The corneal light reflex test is considered normal as long as the light is reflected symmetrically in the same position on both eyes. A reflection at the 2 o’clock position bilaterally represents normal ocular alignment.
D. Document this as an asymmetrical light reflex: An asymmetrical reflex occurs when the light appears in different positions between the two eyes. Since the reflex is symmetrical in this case, it does not indicate asymmetry.
Correct Answer is C
Explanation
A. Inability to understand directions: If the patient could follow other instructions during the assessment, inability to understand directions is unlikely. Cognitive comprehension issues would affect multiple parts of the neurological exam, not just rapid alternating movements.
B. Lesion of cranial nerve IX: Cranial nerve IX (glossopharyngeal) is involved in swallowing and gag reflex, not coordination of limb movements. Lesions here would not explain difficulty with rapid alternating movements.
C. Dysfunction of the cerebellum: The cerebellum coordinates voluntary movements, balance, and fine motor control. Slowness, frequent misses, and inability to perform rapid alternating movements indicate cerebellar impairment, consistent with the patient’s complaints of dropping objects and falling.
D. Vestibular disease: Vestibular dysfunction affects balance and spatial orientation, causing vertigo or unsteadiness. While it may contribute to falling, it does not directly impair rapid alternating limb movements in the manner described.
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