HESI Case Studies Altered, Nutrition Constipation Urinary Patterns (A Graded) Latest Questions and Complete Solutions
Mrs. Loretta Rusk, a 75-year-old client is discharged from the hospital after suffering a cerebral va
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HESI Case Studies Altered, Nutrition Constipation Urinary Patterns (A Graded) Latest Questions and Complete Solutions
Mrs. Loretta Rusk, a 75-year-old client is discharged from the hospital after suffering a cerebral vascular accident (CVA), often referred to 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
A. Aspiration -
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
B. Establish goals
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
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