WILSON- HEALTH ASSESSMENT FOR NURSING PRACTICE, 7TH EDITION

WILSON- HEALTH ASSESSMENT FOR NURSING PRACTICE, 7TH EDITIONISBN: 7775Copyright: 2017Imprint: Mosby7th Edition Marketing ImageEvolve Resources for Health Assessment for Nursing Practice, 6th Editionby Susan Fickertt Wilson, PhD, RN and Jean Foret Giddens, PhD, RN, FAAN, ANEFWILSON- HEALTH ASSESSMENT FOR NURSING PRACTICE, 6TH EDITION Do you know where you are? assesses orientation. If you bought a hat for $5.75 and gave the sales person $10.00, how much change do you expect back? assesses calculation ability. What would you do if a fire started in your home? assesses judgment. What does this phrase “A rolling stone gathers no moss” mean? assesses abstract reasoning. For the nurse to assess mental status, the patient needs to demonstrate abilities such as calculation, judgment, and abstract reasoning. DIF: Cognitive Level: Apply REF: p. 69 | p. 70 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Psychosocial Integrity: Mental Health Concepts 3. While conducting a health history, the nurse asks which questions to assess for risk factors associated with depression? (Select all that apply.) a. Has anyone in your family ever been diagnosed with depression? b. Have you noticed a change in how much energy you have? c. Do you have crying spells? d. Do your muscles seem tense? e. Do you feel that something bad is about to happen to you? f. Do you have difficulty making decisions? ANS: A, B, C, F These questions are related to risk factors for depression. Tense muscles are associated with stress and anxiety rather than depression. Feeling that something bad is about to happen relates to paranoia rather than depression. DIF: Cognitive Level: Apply REF: p. 68 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: NPsUycRhoSsIocNiaGl ITntBCy:OMMental Health Concepts Chapter 08: Nutritional Assessment Wilson: Health Assessment for Nursing Practice, 6th Edition MULTIPLE CHOICE 1. A patient with mild renal disease has been put on a 2200-calorie per day diet plan with the lowest recommended amount of protein. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of protein in the product. The nurse explains, however, that the label is based on 2000 calories. Which is the appropriate formula to teach this patient the least amount of protein he can eat on his prescribed diet? a. 2200 calories 0.15 = 330/9 calories/gram = 36.6 g b. 2200 calories 0.10 = 220/4 calories/gram = 55 g c. 2200 calories 0.20 = 440/9 calories/gram = 48.8 g d. 2200 calories 0.12 = 264/4 calories/gram = 66 g ANS: D Proteins should account for 12% to 20% of total calories. Each gram of protein yields 4 calories. Twelve percent is the least recommended percentage for proteins, rather than 10%. DIF: Cognitive Level: Apply REF: p. 80 TOP: Nursing Process: Implementation MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and Hydration 2. A patient is put on an 1800-calorie a day diet plan. During discharge teaching, the nurse explains to this patient how to use nutrition labels to determine the amount of carbohydrates in the product. The nurse explainsU, hoSweNver,Tthat theOlabel is based on 2000 calories. Which is the appropriate formula to teach this patient of the maximum grams of carbohydrates she can eat on her prescribed diet? a. 1800 calories 0.45 = 810/4 calories/gram = 202.5 g b. 1800 calories 0.60 = 1080/4 calories/gram = 270 g c. 1800 calories 0.55 = 990/9 calories/gram = 110 g d. 1800 calories 0.50 = 900/9 calories/gram = 100 g ANS: B Carbohydrates should account for 55% to 60% of total calories. Carbohydrates should account for a maximum of 60% of total calories rather than 45%. Each gram of carbohydrates yields 4 calories rather than 9. Carbohydrates should account for a maximum of 60% of total calories, rather than 50%. DIF: Cognitive Level: Apply REF: p. 80 TOP: Nursing Process: Implementation MSC: NCLEX Patient Needs: Physiologic Integrity: Basic Care and Comfort: Nutrition and Hydration 3. A patient tells the nurse that she tries to keep her fat intake at less than 15% of her total caloric intake per day. What is the nurse’s most appropriate response to this patient’s comment? a. “That is admirable; how do you accomplish fat intake that low on a daily basis?” b. “Eating fat is essential for good health, and you should consume about 40% of your fats as monounsaturated fat.