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A nurse delivers a tray of food to an older client and sets it
on the overbed table. The client shows no interest in the
food, however. Which actions should the nurse take?
Select all that apply. - ....ANSWER...- Assess the client for
signs of depression.,
- Consult a dietician if the problem persists.,
- Ask why the client does not want to eat anything on the
tray.
The nurse should explore with the client the reason why he
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,does not want to eat anything on the tray. The nurse
should assess for psychological factors that impact
nutrition. Malnutrition is sometimes found with depression
in the older adult population. The nurse and client should
mutually develop a plan to address the lack of nutritional
intake and consult the dietitian as needed. The nurse
should not remove the tray until the reason for the client's
not eating is explored. Crackers and ginger ale may be
offered and an antiemetic administered if nausea is the
reason for the lack of eating, but this is not established.
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,The client with dysphagia has a regular meal tray
delivered at breakfast. Which is the best action for the
nurse to take? - ....ANSWER...Check the medical record
for the client's prescribed diet.
The nurse ensures the client has gotten the correct meal
tray. Often a client on a dysphagia diet will have a special
diet that includes softer or pureed foods and thickened
liquids that aren't available on the regular diet tray. The
other actions are not incorrect, but the client may not be
on a chopped food diet. Sometimes the client with
dysphagia just requires sips between bites, and there is no
reason to use foods from the unit's kitchen area. The best
action the nurse can take is to ensure the client get the
correct meal tray.
The patient states that she feels nauseated and cannot eat:
- ....ANSWER...Remove the tray from the patient's room.
Explore with the patient the desirability of eating small
amounts of foods or liquids, such as crackers or ginger ale,
if the patient's diet permits.
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, Administer antiemetic as prescribed, and encourage
patient to retry small amounts of food after medication
has had time to take effect.
Which question, used for a pain assessment, would assess a
client for the perception of pain? - ....ANSWER..."Do you
find any meaning in your pain?"
The question about interference with sleep is related to the
degree to which the pain interferes with the client's life.
The question about stress relates to the client's use of
adaptive mechanisms to cope with the pain. The question
about meaning assesses the client's perception of pain, and
the question about activity if pain were controlled refers to
the outcomes of pain.
A nurse has just received a client's laboratory results and is
reviewing them. Which finding should the nurse recognize
as an indication of malnutrition or malabsorption? -
....ANSWER...1. Creatinine 1.9 mg/dL (168 μmol/L)
2. Hemoglobin (Hgb) 11.3 g/dL (113 g/L)
3. Hematocrit (Hct) 56% (0.56)
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