NUR 304 Exam 2 - nutritional status--nurse plans interventions r...

NUR 304 Exam 2

• In developing the plan of care, the nurse recognizes pt's dysphagia may impact her fluid and

nutritional status--nurse plans interventions related to pt dysphagia. To which member of the interprofessional team should nurse refer Pt?

• Case manager
• Speech therapist
• Registered dietician
• Geriatric nurse practitioner

Answer Speech therapist (expertise in the evaluation and management of clients with dysphagia

• The nurse recognizes that pt's right-sided weakness is also a factor con- tributing to her risk

for altered nutrition. With which member of the team should the nurse consult regarding this problem?

• OT
• PT
• Speech Therapist
• Doctor

Answer Occupational therapist (expertise in helping clients adapt FINE MOTOR movements for the provision of self care)

• Speech therapist is consulted and makes a home visit to evaluate pt. Therapist determines

dysphagia precautions are needed. The nurse and unlicensed assistive personnel (UAP) arrive at home shortly after therapist eval completed. UAP prepares to assist pt with her non meal and with her personal care. What instruction should nurse provide to UAP ?

• Keep the client in a semi-Fowler's position while bathing her and also while assisting her

with her meal.

• Help feed the client first and then allow her to rest with the head of the bed lowered for 1

hour before bathing her.

• Provide assistance with the meal and then lower the head of the bed to bathe the client and

change the bed linens. 1 / 4

• Bathe the client first and then place the client in a high Fowler's position during and after

the meal.

Answer Bathe client first then place pt in HI-FOWLER's position during and after the meal-- should be kept elecated for at least 1 hour after meal to reduce risk of aspiration

• The nurse visits with pt's husband and observes UAP assist pt with meal. UAP gives pt glass

of iced tea. Considering dysphagia precautions, how should the nurse intervene?

• Remind the UAP to keep track of the fluid intake and output.
• Advise the UAP to provide all fluids at room temperature.
• Instruct the UAP to add a thickening agent to all liquids.
• Establish a fluid restriction for the UAP to follow.

Answer Instruct UAP to add thickening agent to all liquids

• During home visit a week later, nurse assesses pt's nutritional status. Which data indicates the

need for nurse to eval. pt further for altered nutrition? (select all that apply)

• The conjunctival sac is pale in appearance when exposed.
• Blanching occurs when the fingernail bed is compressed.
• The skin over the sternum tents when pinched.
• Bowel sounds are auscultated every 5 seconds.
• The lips are dry and cracked.

Answer

• The conjunctival sac is pale in appearance when exposed.

• The skin over the sternum tents when pinched.
• The lips are dry and cracked.

• Nurse obtains further data regarding Mrs. Rusk's nutritional status. Which info is best to use

for assessment of the client's functional ability related to nutrition

• Amount of groceries the client has in the home.
• Types of food the client has eaten within the last 24 hours.
• The client's ability to feed herself with her left hand. 2 / 4

• The husband's schedule for preparing meals.

Answer client's ability to feed herself with her left hand

• Which intervention should be included in plan of care to provide nurse with the most

accurate information regarding pt ongoing nutritional status?

• Instruct the home health aide to weigh the client once a week.
• Obtain a prescription for a weekly complete blood count.
• Teach Mrs. Rusk how to measure and record her abdominal girth every day.
• Advise Mr. Rusk to perform capillary glucose measurements before every meal.

Answer Instruct home health aide to weigh the client once a week-pattern

• 2 weeks later, nurse notes change in pt weight. Nurse consults w nutritionist, who completes 24

hr calorie count. Nutritionist reports to nurse pt who is 125lb and 67" tall, is consuming 800 cal/day.How should nurse explain results of the cal count to pt and her husband?

• Mrs. Rusk is taking in more calories than she needs and may gain weight.
• Mrs. Rusk is consuming an adequate number of calories for her height.
• Mrs. Rusk's calorie consumption is insufficient and will result in weight loss.
• Since Mrs. Rusk's activity is limited, her caloric intake is sufficient to meet her needs.

Answer Pt calorie consumption is insufficient and will result in weight loss (

• Before notifying the HCP of the data reported by nutritionist, what info is most important

for nurse to obtain?

• Type of vitamin supplement the client is taking.
• Percent of diet composed of carbohydrates.
• Client's calculated body mass index.
• Daily fat gram intake by the client.

Answer 3 / 4

pt BMI

• Nurse reports the data about pt's nutritional status to HCP, who asks nurse to obtain a blood

sample for labs. Nurse obtains copy of lab results the next day. What serum lab value reflects pt's altered nutrion?

• Sodium of 144 mEq/L.
• Calcium of 9.5 mg/dL.
• Potassium of 3.8 mEq/L.
• Protein of 5.0 g/dL.

Answer Protein of 5.0g/dL

(range normal 6.5-8.3g/dL)

• Nurse and nutritionist collaborate to develop plan of care to improve pt nutritional status.

Nurse teaches the pt and family about foods high in protein and provides them with sample menus.Which breakfast selection(s) are good sources of protein?

• Oatmeal with a sliced banana.
• Pancakes with maple syrup.
• Hash browns and an English muffin.
• Scrambled eggs and sausage.
• Egg, potato and onion omelet.

Answer -Scrambled eggs & sausage

-egg, potato and onion omelet

• Nurse also encourages husband to prepare high calorie snacks for pt. Husband states that

his wife loves applesauce and asks if this is a good snack choice. How should nurse response?

• "Do not offer her applesauce because it does not provide very many

calories."

• "Processed foods such as applesauce are often very high in sodium."
• "Provide applesauce since she likes it, along with higher calorie snacks."
• "Applesauce is an excellent source of nutrients and calories."
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