Altered Nutrition - 4066 Words

Altered Nutrition 1. Nursing Process The nurses assessment findings include right sided weakness, slurred speech, and dysphagia. The nurse identifies that Mrs. Rusk is at high risk for several problems. 2. 1. In developing the nursing plan of care, which problem has the highest priority? A. Correct 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 clients plan of care. B. Skin breakdown. This problem is important, but does not have the highest priority when developing the clients plan of care. C. Altered nutrition. This problem is important, but does not have the†¦show more content†¦1. Nutritional Assessment During a home visit a week later, the nurse assesses Mrs. Rusks nutritional status. 2. 7. Which data indicates the need for the nurse to evaluate Mrs. Rusk further for altered nutrition? (Select all that apply.) A. Correct The conjunctival sac is pale in appearance when exposed. The conjunctival sac should be dark pink. Pallor of any mucous membranes may indicate anemia. B. Blanching occurs when the fingernail bed is compressed. This is an expected finding. C. Correct The skin over the sternum tents when pinched. This is an unexpected finding. Skin tenting typically indicates a fluid volume deficit. D. Bowel sounds are auscultated every 5 seconds. This is an expected finding. E. Correct The lips are dry and cracked. This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration. The nurse obtains further data regarding Mrs. Rusks nutritional status. 3. 8. Which data best assesses the clients functional ability related to nutrition? A. Amount of groceries the client has in the home. This assessment provides useful information, but is not related to the clients functional ability. B. Types of food the client has eaten within the last 24 hours. 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