HESI Altered Nutrition - Questions, Answers and Rationales

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HESI Altered Nutrition - Questions, Answers and Rationales Mrs. Loretta Rusk, a 75-year-old client is discharged from the hospital after suffering a cerebral vascular accident (CVA), often referred t... o as a stroke. Mrs. Rusk lives with her elderly husband who is in good health. The primary healthcare provider has prescribed home health skilled nursing visits and home health aide visits 3 times per week. The home health nurse makes the fist home visit to asses Mrs. Rusk and establish the plan of care. NURSING PROCESS The nurse's assessment findings include right sided weakness, slurred speech, and dysphagia. The nurse identifies that Mrs. Rusk is at high risk for several problems. 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. NURSING PROCESS 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. INTERPROFESSIONAL COLLABORATION 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 elevat [Show More]

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