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 D
Explanation
A) Friction rubs: These sounds are typically heard over the liver or spleen and indicate inflammation of the peritoneal surface. They are not standard findings during routine abdominal auscultation and are more specific to certain conditions.
B) Crepitus: This term refers to a crackling or popping sound often associated with joint movement or subcutaneous air and is not related to abdominal auscultation. It is not something a nurse would expect to hear when listening to bowel sounds.
C) Bruits: These are abnormal sounds that indicate turbulent blood flow, typically assessed over blood vessels rather than the abdomen itself. While they can be detected in some abdominal conditions, they are not the primary sounds expected during routine abdominal auscultation.
D) High pitched gurgling: This is characteristic of normal bowel sounds and indicates active peristalsis. High-pitched, gurgling sounds are a common finding during abdominal auscultation, reflecting the movement of gas and fluids in the intestines. This is what the nurse would expect to hear when assessing the abdomen.
Correct Answer is B
Explanation
A) Have the client smile, frown, and puff out their cheeks: This test assesses the facial nerve (cranial nerve VII), not the trigeminal nerve (cranial nerve V). While important for evaluating facial movement, it does not specifically test the motor function of the trigeminal nerve, which is responsible for mastication.
B) Palpate the masseter muscles when the client clenches their teeth: This is the correct test for assessing the motor function of the trigeminal nerve. The trigeminal nerve innervates the muscles responsible for chewing, and palpating the masseter muscles during clenching allows the nurse to evaluate muscle strength and function. It provides insight into the motor capabilities associated with this cranial nerve.
C) Assess constriction of the client's pupils with direct and indirect light: This test evaluates the function of the optic nerve (cranial nerve II) and the oculomotor nerve (cranial nerve III). It does not assess the trigeminal nerve and is not relevant for this assessment.
D) Ask the patient to turn their head left and right with resistance: This action tests the spinal accessory nerve (cranial nerve XI), which is involved in neck movement. It does not relate to the function of the trigeminal nerve, making it an inappropriate choice for this specific assessment.