Clinical Decision Making (CDM) Study Set: Essential Nursing Scenarios and Strategies for Effective Patient Care questions and answers fall 2025

Clinical Decision Making (CDM) Study Set: Essential Nursing Scenarios and Strategies for Effective Patient Care questions and answers fall 2025Clinical Decision Making (CDM) Study Set: Essential Nursing Scenarios and Strategies for Effective Patient Care questions and answers fall 2025Clinical Decision Making (CDM) Study Set: Essential Nursing Scenarios and Strategies for Effective Patient Care questions and answers fall 2025Clinical Decision Making (CDM) Study Set: Essential Nursing Scenarios and Strategies for Effective Patient Care questions and answers fall 2025 1. describe the importance of charting nutritional information in the medical record: helps to remember details of the client's nutritional status, but also provides all other health care professionals to the client's nutritional status nutritional information that is noted in medical records may change the type of treatment that other providers are prescribing charting it may also bring attention to other problems that other providers may have missed refer to your previous note to track trends and see progress (ex: if they eat less it may be why they seem weak during physical therapy 2. identify contacts who will give you the best idea of a client's nutritional status: most of the information should come from the client themselves if possible anyone who lives in the house, client's caregiver, any other member of the healthcare team, medical records communication with entire team is key to understanding their nutritional status 3. what information should be included in a nutritional progress note (8 things): food allergies and intolerances, food likes and dislikes, typical eating habits, percentage of food intake from each meal, current weight and BMI, nutritionally relevent lab work, nutritional diagnosis, and plan for treatment 4. give examples of nonverbal responses that you should be looking for when interviewing a client: where do they look when speaking, are they fidgeting, do they wait for someone else to answer for them make note of their appearance that could be related to nutrition (weak/weight loss) 5. discuss the purpose of an electronic health record (EHR) and what can be found (6): document any interaction with the client and any treatment that the client receives, available for other healthcare professionals involved in treatment to communicate with each other, document client's condition and progress past medical history, demographics, progress notes from other healthcare profes- sionals, prescribed treatments, medications, and relevant images 6. list questions you should ask a client to best evaluate their nutritional status: food allergies, food likes and dislikes, typical eating habits, who does the grocery shopping, who does the cooking, how many meals and snacks are eaten in a day, any recent weight changes, supplement intake, energy levels food diaries are very helpful (weeks worth is ideal, but 24 hour recall is fine) also available by caregiver 7. explain the importance of keeping client information confidential: can be shared with healthcare worker if it is their job, but you need permission otherwise. if it is heard and does not concern you as a healthcare worker, do not repeat. 8. identify critical issues that would make a client be considered a risk (7): has concerns that could cause nutritional concerns, risks such as low food intake, not being able to hold down food, having gastrointestinal disease that impacts nutrient absorption, having a disability making it hard to cook/chew/swallow, malnutrition, evidence of an eating disorder, recent weight loss of 10% body weight over 6 months 9. explain the process of completing a Minimum Data Set (MDS): used by healthcare team to assess client, different sections are filled out by different mem- bers of healthcare team CDM - section K Oral/Nutritional Status -filled out with information you gather from interviewing client, reading medical chart, discussion with other members of healthcare team, Section K: 1. swallowing ability (observable or need speech path referral) 2. height and weight (cdm or registered nurse) 3. weight loss (gathered by client or in medical record 4. nutritional approaches (any nutritional interventions) 5. feeding tubes (record how much formula the client needs through artificial means) 10. explain the difference between subjective and objective information in the medical chart **which should support which: subjective: anything client tells you or judgments made that cannot be measured with data (how they feel when interviewing, way they look when interviewing, how well spouse thinks theyre eating) objective: lab data to show levels are low, documented changes in weight, percent- age of food intake at each meal. objective should support subjective (not always possible) both very important and should be included in medical record 11. why is it important to gather nutrition information from other sources in addition to the client: look in medical records for documents of other healthcare workers of lab work that may provide nutritional information, medication list, and notes from nursing staff about progress if you think client would benefit from another healthcare worker you can refer them (example: recent weight loss could benefit from seeing physical therapist to check strength) 12. identify sensitive ways you would ask about a client's food customs: never make any assumptions, let them share all info with you. tell client you are more than happy to accommodate any food customs and prefer- ences based on their religion never ask why they dont eat a certain food 13. explain how to do carbohydrate counting and when you would use it: used for clients with diabetes due to carbs sugar content when broken down, diabetics need to watch their intake to prevent spikes in blood sugar. need a chart of how many carbs are in different food groups, a physician will have a daily carb limit for the client and spread those carbs throughout the day so the client's blood sugar can remain steady carb limit is dependent on weight, type of diabetes, medications, and amount of insulin they are prescribed 14. explain importance of verifying nutrition information that you record or view in the medical record: what you record is a justification of for their medical treatment, therefore information must be accurate. using subjective and objective information will ensure the accuracy of what is recorded if you suspect they are losing weight, weight them before documenting anything if you think food intake might be low, find in the record where it has been observed verify information by speaking with other members of the healthcare team keep detailed record 15. explain the importance