HESI RN Case Study Altered Nutrition – Flashcards
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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. Risk 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 first home visit to assess Mrs. Rusk and establish the plan of care
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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?
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A. Aspiration 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.
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2. After establishing priorities, the nurse should take which action next in developing Mrs. Rusks's plan of care?
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B. Establish goal The nurse should first complete the assessment, then analyst the assessed data to identify problems, and then establish goals. After the 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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In developing the plan of care, the nurse recognized that Mrs. Rusk's dysphagia may impact her fluid and nutritional status. 3. The nurse plans intervention related to Mrs. Rusk's dysphagia. To which member of the inter professional team should the nurse refer Mrs. Rusk?
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B. Speech therapist Speech therapists have expertise in the evaluation and management of clients with dysphagia.
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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 inter professional team should the nurse consult regarding this problem?
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C. Occupational therapist Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self-care.
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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 the unlicensed assistive personnel (UAP) arrive 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?
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D. Bathe the client first and then place the client in a high Fowler's position during and after the meal. The head of the bed should be elevated to a high fowler's position while the client with dysphagia is eating, and it should be kept elevated for at least 1 hour following the meal to reduce the risk for aspiration.
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The nurse visits with Mr. Rusk and then observes as the UAP assists Mrs. Rusk with her meal. The UAP gives Mrs. Rusk a glad of iced tea to drink. 6. Considering the need for dysphagia precautions, how should the nurse intervene?
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C. Instruct the UAP to add a thickening agent to all liquids. Clients with dysphagia typically have difficulty swallowing liquids, so a thickening agent is added to liquids to change the consistency, making swallowing easier.
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During a home visit a week later, the nurse assesses Mrs. Rusk's nutritional status. 7. Which data indicates the need for the nurse to evaluate Mrs. Rusk further for altered nutrition? (Select all that apply.)
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A. The conjunctival sac is pale and appearance when exposed. (The conjunctival sac should be dark, pink. Pallor of any mucous membranes may indicate anemia.) C. The skin over the sternum tents when pinched. (This is an unexpected finding. Skin tenting typically indicates a fluid volume deficit.) E. The lips are dry and cracked. (This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration.
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The nurse obtains further data regarding Mrs. Rusk's nutritional status. 8. Which information is best to use for assessment of the client's functional ability related to nutrition?
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C. The client's ability to feed herself with her left hand. This assessment provides information about the client's functional ability.
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9. Which intervention should be included in the plan of care to provide the nurse with the most accurate information regarding Mrs. Rusk's ongoing nutritional status?
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A. Instruct the home health aide to weigh the client once a week. Regular measurement of the client's weight provides a useful measurement of the client's general nutritional status. Assessment of the client's pattern of weight gain or loss should be combined with other measures, such as general assessment and dietary evaluation for a thorough picture of the client's nutritional status.
