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?
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?
