How can a nurse best assess a patient's dietary habits effect on their overall health?
Obtain a height and weight and calculate a body mass index (BMI)
Review all medications the patient is taking
Ask about how much food is eaten at an average meal
Assess for the presence of any chronic disease processes
The Correct Answer is A
A) Obtain a height and weight and calculate a body mass index (BMI): Calculating BMI provides a valuable assessment of a patient’s body composition and overall health related to dietary habits. BMI is a widely used indicator that helps categorize individuals into underweight, normal weight, overweight, and obese categories. Understanding where a patient falls within these categories can highlight the potential impact of dietary habits on health and guide further dietary interventions or education.
B) Review all medications the patient is taking: While reviewing medications is important, it primarily focuses on pharmacological management rather than directly assessing dietary habits. Some medications may have dietary restrictions or require specific nutrient intake, but this does not provide a comprehensive view of the patient's overall dietary habits and their effects on health.
C) Ask about how much food is eaten at an average meal: While inquiring about portion sizes is relevant, it does not give a full picture of dietary habits, including food variety, nutrient quality, and frequency of meals or snacks. A single question about average meal size may overlook other critical aspects of the patient’s eating patterns and nutritional intake.
D) Assess for the presence of any chronic disease processes: Evaluating chronic diseases is crucial for understanding health implications, but it does not directly assess dietary habits. Chronic conditions can be influenced by diet, but the assessment of dietary habits requires a more direct inquiry into nutritional intake and lifestyle choices rather than focusing solely on disease presence.
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Correct Answer is A
Explanation
A) VII: The facial nerve (cranial nerve VII) is responsible for controlling the muscles of facial expression. By assessing facial symmetry and movement, the nurse evaluates the integrity and function of this nerve, which is crucial for activities such as smiling, frowning, and raising eyebrows.
B) V: The trigeminal nerve (cranial nerve V) is primarily responsible for sensation in the face and motor functions such as chewing. While it plays a role in facial movement, it does not specifically assess facial expressions.
C) III: The oculomotor nerve (cranial nerve III) controls eye movement and pupil constriction. It does not directly influence facial expressions, so it is not the nerve being assessed in this context.
D) VI: The abducens nerve (cranial nerve VI) is responsible for lateral eye movement. It is unrelated to facial expression or symmetry and is not the focus of this assessment.
Correct Answer is C
Explanation
A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.
B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.
C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.
D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.