Studied by 10 peopleDuring an assessment of a hospitalized patient, the nurse pinches a fold of skin under the clavicle or on the forearm to test the:
a. Mobility and turgor
b. Patient’s response to pain
c. Percentage of the patient’s fat-to-muscle ratio
d. Presence of edema
ANS: A
Pinching a fold of skin under the clavicle or on the forearm is done by the nurse to determine mobility and turgor
The nurse is examining a patient who tells the nurse, “I sure sweat a lot, especially on my face and feet but it doesn’t have an odour.” The nurse knows that this condition could be related to:
a. Eccrine glands.
b. Apocrine glands.
c. Disorder of the stratum corneum.
d. Disorder of the stratum germinativum.
ANS: A
The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odour. The patient’s statement is not related to disorders of the stratum corneum or the stratum germinativum.
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult?
a. Increased vascularity of the skin
b. Increased numbers of sweat and sebaceous glands
c. An increase in elastin and a decrease in subcutaneous fat
d. An increased loss of elastin and a decrease in subcutaneous fat
ANS: D
An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility
During the aging process, the hair can look grey or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:
a. Metrocytes.
b. Fungacytes.
c. Phagocytes.
d. Melanocytes.
ANS: D
In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks grey or white and feels thin and fine. The other options are not correct
During an examination, the nurse finds that a patient has excessive dryness of the skin. When charting, the nurse describes this condition as:
a. Xerosis.
b. Pruritus.
c. Alopecia.
d. Seborrhea
ANS: A
Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin
A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should inform her that acne:
a. Is contagious.
b. Has no known cause.
c. Is caused by increased sebum production.
d. Has been found to be related to poor hygiene.
ANS: C
Approximately 90% of males and 80% of females will experience acne; causes are increased sebum production and epithelial cells that do not desquamate normally.
A 75-year-old woman with a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse encourages her to stop trying to remove the corn with scissors because:
a. Her actions could increase her risk for infection and lesions because of her chronic disease.
b. She has increased circulation to her foot because of her diabetes, and it could cause severe bleeding.
c. She is 75 years old and has vision issues, which places her at greater risk for self-injury with the scissors.
d. Her range of motion is limited because of her peripheral vascular disease, and she may not be able to reach the corn safely.
ANS: A
A personal history of diabetes and peripheral vascular disease increases a person’s risk for skin lesions in the feet or ankles. The patient needs to seek professional assistance for corn removal.
While assessing a patient’s skin, the nurse notes multiple skin fissures on the hands. The nurse recognizes this as:
a. Diaphoresis in the patient.
b. Potential openings for bacterial infection.
c. Poor temperature regulation.
d. Impaired perception to pain.
ANS: B
The skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from within the body. Fissures or cracks in the skin result from extreme dryness. These fissures are openings in the skin which can allow bacteria to enter the body.
A patient comes in for a physical examination and complains of “freezing to death” while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to:
a. Venous pooling.
b. Peripheral vasodilation.
c. Peripheral vasoconstriction.
d. Decreased arterial perfusion.
ANS: C
A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness (see Table 13-1).
A 62-year-old patient with heart failure comes to the clinic for his annual examination. During skin assessment, the nurse notes slight swelling to the patient’s feet, and indentations which quickly fade when both feet are palpated. The nurse will chart this finding as:
a. No edema noted.
b. Unilateral deep pitting 3+ edema.
c. Bilateral moderate pitting 2+ edema.
d. Mild pitting 1+ edema.
ANS: C
Some problems, such as heart failure or kidney failure, can cause bilateral edema in the extremities. Edema is graded on a four-point scale:
1+: Mild pitting, slight indentation, no perceptible swelling of the leg
2+: Moderate pitting, indentation subsides rapidly
3+: Deep pitting, indentation remains for a short time, swelling of leg
4+: Very deep pitting, indentation lasts a long time, gross swelling and distortion of leg
A patient is especially worried about the white coloration of an area of skin on her feet, and she has been told it is vitiligo. The nurse explains that vitiligo is:
a. Caused by an excess of melanin pigment.
b. Caused by an excess of apocrine glands in her feet.
c. Caused by the complete absence of melanin pigment.
d. Related to impetigo and can be treated with an ointment.
ANS: C
Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise, the depigmented skin is normal
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed.
When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding?
a. Colour variation
b. Border regularity
c. Symmetry of lesions
d. Diameter of less than 6 mm
ANS: A
Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, colour variation, and diameter greater than 6 mm.
During a skin assessment, the nurse initially is concerned that the patient who is of East Asian origin has skin that is yellowish-brown. On further assessment, the nurse notes that the skin on the hard and soft palate is pink and the patient’s sclerae are not yellow. From this finding, the nurse recognizes that the patient likely does not have:
a. Pallor.
b. Jaundice.
c. Cyanosis.
d. Iron deficiency.
ANS: B
Jaundice is exhibited by yellow coloration, which indicates rising levels of bilirubin in blood.
Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the sclerae.
A patient of African origin is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient’s skin?
a. Ruddy blue
b. Generalized pallor
c. Ashen, grey, or dull
d. Patchy areas of pallor
ANS: C
Pallor attributable to shock, with decreased perfusion and vasoconstriction, in dark-skinned people will cause the skin to appear ashen, grey, or dull (see Table 13-2)
An older adult woman is brought to the emergency department after she was found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination?
a. Smooth mucous membranes and lips
b. Dry mucous membranes and cracked lips
c. Pale mucous membrane
d. White patches on the mucous membranes
ANS: B
With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, “What causes these liver spots?” The nurse tells her, “They are:
a. “Signs of decreased hematocrit related to anemia.”
b. “Caused by the destruction of melanin in your skin from exposure to the sun.”
c. “Clusters of melanocytes that appear after extensive sun exposure.”
d. “Areas of hyperpigmentation related to decreased perfusion and vasoconstriction.”
ANS: C
Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. The nurse documents this finding as a:
a. Bulla.
b. Wheal.
c. Nodule.
d. Papule.
ANS: D
A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is caused by superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm
The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition?
a. Severe obesity
b. Childhood growth spurts
c. Severe dehydration
d. Connective tissue disorders, such as scleroderma
ANS: C
Decreased skin turgor is associated with severe dehydration or extreme weight loss.
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in colour. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition?
a. Heart failure
b. Venous thrombosis
c. Local inflammation
d. Blockage of lymphatic drainage
ANS: A
Bilateral edema or edema that is generalized over the entire body is caused by a central problem, such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.
A 40-year-old woman reports a change in mole size, accompanied by colour changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
a. Tell the patient to watch the lesion and report back in 2 months.
b. Refer the patient for further assessment because of the risk for melanoma based on signs and symptoms.
c. Ask additional questions regarding environmental irritants that may have caused this condition.
d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.
ANS: B
The ABCD danger signs of melanoma are asymmetry, border irregularity, colour variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral
The nurse is assessing a patient with emphysema for clubbing of the fingernails, which is confirmed by:
a. Nail bases that are firm and slightly tender.
b. Curved nails with a convex profile and ridges across the nails.
c. Nail bases that feel spongy with an angle of the nail base of 150 degrees.
d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.
ANS: D
The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy
The nurse is performing an assessment for jaundice in a patient who has liver disease. Which of these assessment findings is indicative of true jaundice?
a. Yellow patches in the outer sclera
b. Yellow coloration of the sclera that extends up to the iris
c. Skin that appears yellow when examined under low light
d. Yellow deposits on the palms and soles of the feet where jaundice first appears
ANS: B
The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.
The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best?
a. Assessing the skin for cyanosis and swelling
b. Assessing the oral mucosa for generalized erythema
c. Palpating the skin for edema and increased warmth
d. Palpating for tenderness and local areas of ecchymosis
ANS: C
Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary
A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the past 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration and tests skin mobility and turgor over the infant’s:
a. Sternum.
b. Forehead.
c. Forearms.
d. Abdomen.
ANS: D
Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.
The nurse is assessing a 50-year-old patient who is restricted to the bed. The patient has limited mobility and needs to be frequently repositioned. The nurse will use the Braden Scale to assess for:
a. Mobility and positioning needs.
b. Risk for developing pressure ulcers.
c. Progression of limitations.
d. Cognitive status and functioning.
ANS: B
The Braden Scale is used for predicting the risk for pressure sores, (See Table 13-1.)
The nurse is performing a Braden Scale assessment on a 65-year-old bedbound patient with limited mobility. The patient is unable to communicate needs or discomfort but does respond to verbal commands. The nurse notes that the patient’s skin is moist and will likely require a linen change each shift. The patient is confined to the bed with no ability to walk and makes very limited changes to body extremities occasionally. The patient requires frequent repositioning with maximum assistance. The patient eats about half of the food offered. The nurse charts the findings as:
a. At risk for pressure ulcers.
b. Low risk for pressure ulcer development.
c. Moderate risk for pressure ulcers.
d. High Risk for developing pressure ulcers.
ANS: D
The nurse initiates a Braden Scale assessment of the 85-year-old patient who is independent with activities of daily living and frequently ambulates around the unit. The patient scores a 23 which the nurse documents as:
a. At increased risk for pressure ulcers.
b. No risk for pressure ulcer development.
c. Requires monthly Braden Scale assessment.
d. Initiate a weekly assessment schedule.
ANS: B
The full score attainable is 23, indicating that the patient is not at risk for pressure ulcer development. See Table 13-1 For Braden Scale Assessment for Predicting Pressure Ulcer Risk.
The nurse is working with the older adult population, and recognizes that the aging process can increase: (Select all that apply.)
a. Heat stroke risk.
b. Skin vascularity.
c. Occurrence of skin tear injuries.
d. Muscle tone.
e. Time for a wound to heal.
f. Skin elasticity.
ANS: A, C, E
Elastin, collagen, and subcutaneous fat are lost, as is muscle tone. The loss of collagen increases the risk for shearing and tearing injuries. The vascularity of the skin diminishes while the vascular fragility increases. When skin breakdown does occur, subsequent cell replacement is slower, and wound healing is delayed
The nurse recognizes the importance of assessing the patient’s skin as the skin has many protective and adaptive functions which include: (Select all that apply.)
a. Protection from bacterial intrusion.
b. Increasing dehydration through water loss.
c. Regulation of body temperature.
d. Supporting wound healing.
e. Decreasing the wastes excreted.
ANS: A, C, D
The skin is a waterproof, highly resilient covering that has protective and adaptive properties. Some of the functions include:
• Protection: the skin protects the body from injury from physical, chemical, thermal, and light wave sources.
• Barrier: the skin stops the invasion of microorganisms and loss of water and electrolytes from within the body.
• Temperature regulation: the skin allows heat dissipation through sweat glands and heat storage through subcutaneous insulation.
• Wound repair: the skin allows cell replacement of surface wounds.
• Absorption and excretion: the skin allows limited excretion of some metabolic wastes, by-products of cellular decomposition such as minerals, sugars, amino acids, cholesterol, uric acid, and urea.
When providing patient education on nutrition the nurse explains optimal nutritional status as:
a. Consuming food in excess of daily body requirements.
b. Consuming energy-dense foods to meet the minimum body needs.
c. Food intake to meet daily body requirements but not to support increased metabolic demands.
d. Consuming nutrients to meet daily body requirements and support increased metabolic demands.
ANS: D
Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands resulting from growth, pregnancy, or illness
The nurse is providing nutrition information to the mother of a 1-year-old child. Which of these statements represents accurate information for this age group?
a. Maintaining adequate fat and caloric intake is important for a child in this age group.
b. The recommended dietary allowances for an infant are the same as for an adolescent.
c. The baby’s growth is minimal at this age; therefore, caloric requirements are decreased.
d. The baby should be placed on skim milk to decrease the risk for coronary artery disease at a later age.
ANS: A
Because of rapid growth, especially of the brain, both infants and children younger than 2 years of age should not drink skim or low-fat milk or be placed on low-fat diets. Fats (calories and essential fatty acids) are required for proper growth and central nervous system development
A pregnant woman is interested in breastfeeding her baby and asks several questions about it.
Which information is appropriate for the nurse to share with her?
a. Breastfeeding is best when also supplemented with bottle feedings.
b. Babies who are breastfed often require supplemental vitamins.
c. Breastfeeding is recommended for infants for the first 2 years of life.
d. Breast milk provides the nutrients necessary for growth and natural immunity.
ANS: D
Breastfeeding is recommended for full-term infants for the first year of life because breast milk is ideally formulated to promote normal infant growth and development and natural immunity. The other statements are not correct
A mother and her 13-year-old daughter express concern related to the daughter’s recent weight gain and her increase in appetite. Which of these statements represents information the nurse should discuss with them?
a. Dieting and exercising are necessary at this age.
b. Snacks should be high in protein, iron, and calcium.
c. Teenagers who have a weight problem should not be allowed to snack.
d. A low-calorie diet is important to prevent the accumulation of fat.
ANS: B
After a period of slow growth in late childhood, adolescence is characterized by rapid physical growth and endocrine and hormonal changes. Caloric and protein requirements increase to meet this demand. Because of bone growth and increasing muscle mass (and, in girls, the onset of menarche), calcium and iron requirements also increase
The nurse is meeting a patient who has no history of nutrition-related problems for the first clinic visit. The initial nutritional screening should include which activity?
a. Calorie count of nutrients
b. Anthropometric measures
c. Complete physical examination
d. Measurement of weight and weight history
ANS: D
The parameters used for nutrition screening typically include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. The other responses reflect a more
A patient is asked to indicate on a form how many times he eats a specific food. Which method is the nurse using to assess nutritional intake?
a. Food diary
b. Calorie count
c. 24-hour recall
d. Food-frequency questionnaire
ANS: D
With this tool, information is collected on how many times per day, week, or month the individual eats particular foods, which provides an estimate of usual intake
The nurse is providing care for a 68-year-old woman who is complaining of constipation.
What concern exists regarding her nutritional status?
a. Absorption of nutrients may be impaired.
b. Constipation may represent a food allergy.
c. The patient may need emergency surgery to correct the problem.
d. Gastrointestinal problems will increase her caloric demand.
ANS: A
Gastrointestinal symptoms, such as vomiting, diarrhea, or constipation, may interfere with nutrient intake or absorption. The other responses are not correct
During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?
a. Certain medications can affect the metabolism of nutrients.
b. The nurse needs to assess the patient for allergic reactions.
c. Medications need to be documented in the record for the physician’s review.
d. Medications can affect memory and ability to identify food eaten in the last 24 hours.
ANS: A
Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are medications that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.
The nurse is performing a nutritional assessment on a 15-year-old girl, who tells the nurse that she is “so fat.” Assessment reveals that she is 1.6 m tall and weighs 50 kg. An appropriate response from the nurse would be:
a. “How much do you think you should weigh?”
b. “Don’t worry about it; you’re not that overweight.”
c. “The best thing for you would be to go on a diet.”
d. “I used to always think I was fat when I was your age.”
ANS: A
Adolescents’ increased body awareness and self-consciousness may cause eating disorders, such as anorexia nervosa or bulimia, conditions in which the real or perceived body image does not compare favourably with an ideal image. The nurse should not belittle the adolescent’s feelings, provide unsolicited advice, or agree with her.
The nurse is discussing appropriate foods with the mother of a 3-year-old child. Which of these foods are recommended?
a. Foods that the child will eat, no matter what they are
b. Foods easy to hold such as hot dogs, nuts, and grapes
c. Any foods, as long as the rest of the family is also eating them
d. Finger foods and nutritious snacks that cannot cause choking
ANS: D
Small portions, finger foods, simple meals, and nutritious snacks help improve the dietary intake of young children. Foods likely to be aspirated should be avoided (e.g., hot dogs, nuts, grapes, round candies, popcorn)
The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult?
a. Increase in taste and smell
b. Living alone on a fixed income
c. Change in cardiovascular status
d. Increase in gastrointestinal motility and absorption
ANS: B
Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an older adult’s nutritional status.
During assessment of a 78-year-old patient taking multiple medications for various chronic conditions, the nurse is concerned that the patient is experiencing:
a. Increase in hair growth.
b. Inadequate nutrient food intake.
c. Extreme weight gain.
d. Increase in abdominal fat.
ANS: B
Older adults are prescribed multiple medications that may interact with nutrients, vitamin supplements, and other prescription medications
A 21-year-old woman with extensive weight gain over the past 12 months, has a BMI of 38, indicating obesity. The nurse is concerned that she is at increased risk for:
a. Polypharmacy.
b. Diabetes.
c. Optimal nutrition.
d. Low mortality.
ANS: B
Excess body weight is associated with numerous chronic conditions, including type 2 diabetes, hypertension, cardiovascular disease, gallbladder disease, and certain types of cancer.
The nurse is performing a nutritional assessment on an 80-year-old patient. The nurse knows that physiological changes can directly affect the nutritional status of the older adult and include:
a. Slowed gastrointestinal motility.
b. Hyperstimulation of the salivary glands.
c. Increased sensitivity to spicy and aromatic foods.
d. Decreased gastrointestinal absorption causing esophageal reflux.
ANS: A
Normal physiological changes in aging adults that affect nutritional status include slowed gastrointestinal motility, decreased gastrointestinal absorption, diminished olfactory and taste sensitivity, decreased saliva production, decreased visual acuity, and poor dentition
A 16-year-old girl is being seen at the clinic for gastrointestinal complaints and weight loss. The nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, and high caffeine intake. In this situation, which is most appropriate when collecting current dietary intake information?
a. Scheduling a time for direct observation of the adolescent during meals
b. Asking the patient for a 24-hour diet recall and assuming it to be reflective of a typical day for her
c. Having the patient complete a food diary for 3 days, including 2 weekdays and 1 weekend day
d. Using the food frequency questionnaire to identify the amount of intake of specific foods
ANS: C
Food diaries require the individual to write down everything consumed for a certain time period. Because of the erratic eating patterns of this individual, assessing dietary intake over a few days would produce more accurate information regarding eating patterns. Direct observation is best used with young children or older adults.
The nurse is working with a number of patients with liver disease from excessive alcohol consumption. The nurse recognizes that these patients are at risk for:
a. Weight loss from alcohol consumption replacing caloric food intake.
b. Undernutrition from consuming alcohol in place of nutritious foods.
c. Obesity from a fatty liver.
d. Overnutrition with the increased calories from alcohol consumption.
ANS: B
Tobacco, alcohol, and illicit drug use are agents often substituted for nutritious foods and increase requirements for some nutrients. Individual is at risk for undernutrition with poor intake of necessary nutrients
A 70-year-old female patient has been brought to the emergency department after a fall in her home. The patient is a widow and has become socially isolated. The nurse assesses the patient for undernutrition and radiography reveals that she has osteoporosis, which is a deficiency of:
a. Iron.
b. Riboflavin.
c. Vitamin D and calcium.
d. Vitamin C.
ANS: C
Calcium and vitamin D deficiencies are associated with osteoporosis. Iron deficiency would result in anemia, riboflavin deficiency would result in magenta tongue, and vitamin C deficiency would result in scurvy
The nurse recognizes which of these persons as being at risk for undernutrition? (Select all that apply.)
a. A 28-year-old living in his car
b. A 50-year-old female bank manager
c. A 27-year-old university graduate student
d. A 30-year-old hospital administrator
e. A 5-month-old infant
f. A 12-year-old recently relocated from Syria
ANS: A, E, F
Vulnerable groups for undernutrition are infants, children, pregnant women, recent immigrants, persons with low incomes, hospitalized people, and aging adults
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