HESI RN Cases Studies: Altered Nutrition

HESI RN Cases Studies: Altered Nutrition 1. In developing the nursing plan of care, which problem has the highest priority? A. Aspiration B. Skin Breakdown C. Altered nutrition D. Self care deficit Rationale: Aspiration, or the entry of foreign substances such as food or fluids into the lungs, may cause hypoxia or respiratory distress. Therefore, this is the highest priority in establishing the client's plan of care. 2. After establishing priorities, what action should the nurse take next in developing Mrs. Rusk's plan of care? A. Analyze data B. Establish goals C. Complete an assessment D. Implement interventions Rationale: the nurse should first complete assessment, then analyze data to identify problems, and then establish goals. After goals and expected outcomes are established, the nurse plans and implements interventions, which are then evaluated to determine if the expected outcomes and goals were accomplished INTERPROFESSIONAL COLLABORATION In developing the plan of care, the nurse recognizes that Mrs. Rusk's dysphagia may impact her fluid and nutritional status. 3.The nurse plans interventions related to Mrs. Rusk's dysphagia. Which member of the interdisciplinary team should the nurse refer Mrs. Rusk? A. Case manager B. Speech therapist C. Registered dietician D. Geriatric nurse practitioner Rationale: Speech therapists have expertise in the evaluation and management of clients with dysphagia. The nurse recognizes that Mrs. Rusk's right-sided weakness is also a factor contributing to her risk for altered nutrition. 4. With which member of the interdisciplinary team should the nurse consult regarding this problem? A. Bariatrics specialist B. Clinical nutritionist C. Occupational therapist D. Rehabilitation counselor Rationale: Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self care. DYSPHAGIA PRECAUTIONS The speech therapist is consulted and makes a home visit to evaluate Mrs. Rusk. The therapist determines that dysphagia precautions are needed. The nurse and unlicensed assistive personnel (UAP) arrives at the home shortly after the therapist's evaluation is completed. The UAP prepares to assist Mrs. Rusk with her noon meal and with her personal care. 5. What instruction should the nurse provide the UAP? A. Keep the client in a semi-Fowler's position while bathing her and also while assisting her with her meal B. Help feed the client first and then allow her to rest with the head of the bed lowered for 1 hour before bathing her C. Provide assistance with the meal and then lower the head of the bed to bathe the client and change the bed linens D. Bathe the client first and then place the client in a high Fowler's position during and after the meal. Rationale: The head of the bed should be elevated to a high Fowler's position while the client with dysphagia is eating, and kept elevated for at least 1 hour following the meal to reduce the risk for aspiration The nurse visits with Mr. Rusk and then observes as the UAP assists Mrs. Rusk with her meal. The UAP gives Mrs. Rusk a glass of iced tea to drink. 6. Considering the need for dysphagia precautions, how should the nurse intervene? A. Remind the IAP to keep track of the fluid intake and output B. Advise the UAP to provide all fluids at room temperature C. Instruct the UAP to add a thickening agent to all liquids D. Establish a fluid restriction for the UAP to follow Rationale: Clients with dysphagia typically have difficulty swallowing liquids, so a thickening agent is added to liquids to change the consistency, making swallowing easier. NUTRITIONAL ASSESSMENT During a home visit a week later, the nurse assesses Mrs. Rusk's nutritional status. 7. Which data indicates the need for the nurse to evaluate Mrs. Rusk further for altered nutrition? (Select all the apply.) A. The conjunctival sac is pale in appearance when exposed B. Blanching occurs when the fingernail bed is compressed C. The skin over the sternum tents when pinched D. Bowel sounds are auscultated every 5 seconds E. The lips are dry and cracked A. The conjunctival sac is pale in appearance when exposed Rationale: The conjunctival sac should be dark pink. Pallor of any mucous membranes may indicate anemia. C. The skin over the sternum tents when pinched Rationale: This is an unexpected finding. Skin tenting typically indicates a fluid volume deficit. E. The lips are dry and cracked - Rationale: This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration. The nurse obtains further data regarding Mrs. Rusk's nutritional status. 8. Which data best assesses the client's functional ability related to nutrition? A. Amount of groceries the client has in the home B. Types of food the client has eaten within the last 24 hours C. The client's ability to feed herself with her left hand D. The husband's schedule for preparing meals Rationale: This assessment provides information about the client's functional ability. 9. In planning care, which intervention should be included to provide the nurse with the most accurate information regarding Mrs. Rusk's ongoing nutritional status? A. Instruct the home health aide to weigh the client once a week B. Obtain a prescription to draw a complete blood count weekly C. Teach Mrs. Rusk how to measure and record her abdominal girth every day D. Advice Mr. Rusk to perform capillary glucose measurements before every meal Rationale: Regular measurement of the client's weight provides a useful measurement of client's general nutritional status. Assessment of the client's pattern of weight gain or loss should be combined with other measures, such as general assessment and dietary evaluation for a thorough picture of the client's nutritional status.