HESI Altered Nutrition

Question 1

Scenario

Answer 1

Older client is discharged from the hospital to rehab after suffering as cerebral vascular accident (CVA) often referred to as a stroke. The client lives with her spouse who is in good health. The rehab nurse enters the room to assess the client.

Question 2

The nurses assessment, findings include right, sided weakness, slurred, speech, and dysphagia. The nurse identifies that the client is at a high risk for several problems.

Of the clients problems addressed on the nursing plan of care which is the highest priority problem ?

Answer 2

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, and establishing the clients plan of care.

Question 3

After establishing priorities, the nurse should take which action next and developing the clients plan of care?

Answer 3

Establish outcomes
Rationale: the nurse should first complete the assessment and analyze the assessed data to identify problems, and then establish outcomes after the expected outcomes are established the nurse plans and implements interventions, which are evaluated determine if the expected outcomes were accomplished

Question 4

The nurse visits the client spouse, and then observes as the UAP assist the client with her meal. The UAP gives her a glass of iced tea to drink in. The client begins to cough. The nurse recognizes that the clients dysphagia may impact her fluid and nutritional status.

Nurse plans interventions related to the clients dysphagia to which member of the interprofessional team. Should the nurse obtain referral order?

Answer 4

Speech therapist
Rationale: speech therapist have expertise in the evaluation and management of clients with dysphagia

Question 5

The nurse recognizes that the clients right sided weakness is also a factor contributing to a risk of altered nutrition

With which member of the interprofessional team should the nurse consult regarding this problem?

Answer 5

Occupational therapist
Rationale: occupational therapist, have expertise in helping clients adapt, fine motor movements for the provision of self-care

Question 6

The speech therapist is consulted to evaluate the client. The therapist determines that dysphasia precautions are needed and writes in order for purée, diet and honey thickened liquids. the nurse and UAP enter the clients room shortly after the therapist evaluation is complete the UAP prepares to assist the client with her noon meal with her personal care

What instructions should the nurse provide to the UAP?

Answer 6

Pay the client first and then placed the client in the high Fowlers position during and after the meal

Rational: the head of the bed should be elevated to a high Fowlers position, while the client with dysphagia is eating, and it should be kept elevated for at least one hour following the meal, to reduce the risk of aspiration

Question 7

Considering the need for dysphagia precautions, what action should the nurse implement intervene?

Answer 7

Instruct the UAP to add a thickening agent to all liquids
Rationale: clients with dysphagia typically have difficulty swallowing liquids, so thickening agent is added to liquids to change the consistency, making swallowing easier

Question 8

Three days later, the nurse assesses the clients nutritional status

Which data indicates the need for the nurse to evaluate the client further for altered nutrition?

Answer 8

1. The conjunctival sack is pale and appearance when exposed.
   Rationale: the conjunctival sack should be a dark pink pillar of any mucous membranes may indicate anemia
2. The skin over the sternum tents when pinched.
   Rationale this is an unexpected, finding skin tenting typically indicates a fluid volume deficit
3. The lips are dry and cracked.
   Rationale: this is an unexpected, finding for someone with adequate nutrition, and could be a sign of dehydration

Question 9

The nurse obtains further data regarding the clients nutritional status

Which information is best to use for assessment of the clients, functional ability related to nutrition?

Answer 9

The clients ability to feed herself with her left hand
Rationale: this assessment provides information about the clients functional ability

Question 10

Which intervention should be included in the plan of care to provide the nurse with the most accurate information regarding the clients ongoing nutritional status?

Answer 10

Instruct the UAP to weigh the client once a week
Rationale: regular measurement of the clients weight provides a useful measurement of the client, general nutritional status assessment of the clients 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 clients nutritional status

Question 11

A week later, the nurse notes a change in the clients wait the nurse consult with the nutritionist who helps complete a 24 hour calorie count the nutritionist reports back to the nurse that the client, wait 110 pounds is 67 inches tall and is consuming 700 cal per day

How should the nurse explain the results of the calorie count to the client spouse?

Answer 11

Her calorie consumption is insufficient and will result in weight loss
Rationale: an average adult requires 20 to 35 cal per kilogram per day the client who weighs 110 pounds (50 kg) needs a minimum of 1000 cal per day to maintain her weight

Question 12

Before notifying the healthcare provider of the data reported by the nutritionist, what information is most important to the nurse to obtain?

Answer 12

Client calculated body mass index

Rationale: the body mass index is calculated based on the clients height and weight, and provides a picture of the clients current nutritional status regarding over or under nutrition

Question 13

The nurse reports the data about the clients nutritional status to the HCP who ordered several lab tests. The nurse obtains a copy of the lab results the next day.

Which serum lab value reflects, altered nutrition?

Answer 13

Protein of 5.0 g/dL
Rationale: the range for a normal serum protein level and an adult is 6.42 8.3 g/dL

Normal ranges:
Sodium: 135-145 mEq/L
Calcium: 8.6-10.2 mg/dl
Potassium: 3.5-5 mEq/L
Protein: 6.4-8.3 g/dL

Question 14

The healthcare provider prescribes an appetite, stimulant and ask the nutritionist to consult with the client and her family regarding her dietary needs the nurse and nutritional collaborate to develop a plan of care to improve the clients nutritional status. The nurse teaches the client and her spouse about foods that are high in protein and provide them with sample menus.

Which breakfast selections are good sources of protein?

Answer 14

1. Scrambled eggs and sausage

Rationale: both eggs and sausages are good sources of proteins

2. Egg, potato, and onion omelet

Rationale: an egg, potato and onion omelette is a good source of protein and also provides minerals and vitamins

Question 15

The clients husband states that his wife loves applesauce and ask us if this is a good snack choice which response by the nurses best?

Answer 15

Offer her applesauce and she likes it along with high calorie snacks

Rationale: to improve the clients nutrition, the nurse needs to consider the likes and dislikes of the client in addition to the needed nutrients, combining applesauce which the client likes, but which is not a high calorie snack with snacks that contain more calories best meats the needs for the client

Question 16

The client has a new prescription for an appetite stimulant

Which information about the drug should the nurse obtain prior to educating the client regarding the time the medication will be administered?

Answer 16

Onset of action

Rational: the nurse should determine when the drug will start to take affect so that the medication can be taken when the greatest therapeutic effect can be achieved

Question 17

The client spouse inquires about the newly prescribed medication, which is a brand name, drug and states “ when we fill this prescription. I hope we can get this in the generic form. Maybe it won’t be as expensive.”

How should the nurse respond?

Answer 17

Your pharmacist and healthcare provider can determine if there is a generic drug that is a safe alternative to the brand-name drug.

Rationale: although brand and generic medication’s are bio equivalent, the inner ingredients may vary, sometimes resulting in different effects. Therefore, the healthcare provider must approve the substitution of a generic form for a prescribed brand name medication.

Question 18

The client gradually weekends, and is admitted to the medical unit her HCP recommends the insertion of a feeding tube by means of percutaneous esophageal gastrectomy (PEG). She signed the consent form in the procedure scheduled for the next day that evening the nurse notes that the clients medical record contains an advanced directive requesting that she should not be resuscitated in the event of an arrest, which is confirmed in the prescriptions written by the HCP while the nurse is conversing with the client and her spouse. They both confirmed that no measure should be taken to save her life

Which action should the nurse take to ensure the clients DNR status?

Answer 18

Advise the client that she will need to sign a case form that will be placed in her chart, and according to their protocol or wristband will be placed on her identifying that she should not be resuscitated

Rationale: order in the clients chart and an identifying wristband indicating that resuscitation should not be performed help ensure that the clients wishes are known and respected

Question 19

The next morning, the nurse enters the clients room to repair her to go to the procedure room. The nurse states that the procedure is scheduled in 30 minutes the client who is lethargic. Tell the nurse she has changed her mind does not want the procedure performed stating that she would just rather go and die her spouses in the room and is very upset by her comment.

What action should the nurse implement regarding cancellation of the procedure?

Answer 19

Provide a couple with privacy to discuss the decision

Rationale: the nurse must address the clients expressed desire to cancel the procedure. The nurses initial action should include, allowing the couple privacy to discuss the decision adjusting any concerns of the client and encouraging further communication.

Question 20

The couple discusses decision together, and the client decides to have the procedure scheduled. She taken to the procedure room where PEG tube is inserted following the surgery. The client returns to a room following the insertion of the PEG tube. She has an IV of lacerated, ringer solution and fusing at 50 mL but does not have any feeding solution attached to the PEG tube

Which initial action should the nurse implement?

Answer 20

Continue to monitor the client without infusing any solution through the PEG tube
Rationale: feeding supplements are typically initiated when bowel sounds are present usually within 24 hours after PEG tube is inserted

Question 21

The nurse observes that the dressing around the PEG tube insertion site is intact with a small amount of serosanguinous drainage

What action should the nurse implement?

Answer 21

Circle. The amount of drainage on the initial dressing.

Rationale: circling the small amount of drainage, allows the nurse to compare any changes in the amount of drainage at a later time

Question 22

The next day, the nurse initiates the feeding prescribed by the HCP. The prescription is for the formula to infused at 30 mL/hour. The formula is available in 8 ounce cans the nurses preparing enough formula for 12 hours.

How many cans of formula will the nurse need?

Answer 22

1.5

Rationale: the nurse needs a total of 360 mL (12 hours x 30 mL/hour)
An 8 ounce can of formula contains 240 mL (8 ounces x 30 mL/ounce)
360 mL / 240 mL = 1.5 cans

Question 23

After infusing the formula at 30 mL an hour for six hours, the nurse checks, the clients residual volume and obtain 75 mL the prescription for the formula states that the rate should be increased by 10 mL an hour as long as the clients residual volume is less than half of the previous infused total volume

What action should the nurse implement?

Answer 23

Increase the rate of the formula to 40 mL an hour
Rationale: the client has received 180 mL are in the previous six hours half of that volume is 90 mL (180÷2). The residual volume obtained was 75 mL so the rate of the formula should be increased by 10 mL an hour to 40 mL an hour 

Question 24

Overtime the continuous feeding is increased to 80 mL/hour. The nurse plants educate the client spouse on how to manage the continuous feeding when his wife is discharged.

Before the nurse educates the client and her spouse about managing the continuous feed, what information is most important for the nurse to collect prior to providing discharge instructions?

Answer 24

Determine if the client and her husband feel ready to learn the skill
Rationale: readiness to learn, as essential for effective teaching at the clients husband expresses a lack of readiness to learn other resources will have to be initiated before his wife is discharged home

Question 25

When the nurse demonstrates the use of the feeding equipment. The clients spouse looks away. The nurse observes that he is crying

What action should the nurse implement?

Answer 25

Acknowledge the stressful nature of the situation and ask him if he feels ready to continue

Rationale: this is a therapeutic response, offering support and allowing the spouse to feel in control of the situation

Question 26

The feedings are changed to bolus feedings three times a day after receiving instruction, the client spouse demonstrates correct ability to perform the skill and states that he feels he can handle this responsibility. The client is discharged home and home. Health care services are initiated. during a home visit the nurse observes the client spouse, administering a bullet feeding to the client who is sitting upright in bed after checking the residual volume he pours the feeding into a syringe attached to the feeding tube. He then holds the syringe upright while the feeding tube enters the stomach.

And observing this procedure what action should the nurse take?

Answer 26

Ensure that he flushes the tea with water after the syringe is empty of feeding

Rationale: flushing, the syringe and tubing with water, reduces the risk for obstruction of the tubing

Question 27

The client tells the nurse that she has had 5 to 7 liquid diarrhea stools a day for the last two days

What is the sequence of nursing actions?

Answer 27

1. Tell the spouse to hold the remaining feeding
2. Auscultate for the presence of bowel sounds.
3. Assess the elasticity of the client skin.
4. Notify the HCP of diarrhea.

Rationale: first initial action is to tell the spouse to hold the remaining feeding until further assessment can be obtained second osculate for bowel sounds to determine if they are hyperactive or hypo active bowels third assess elasticity determine whether the client is dehydrated and will need further hydration finally notify the HCP about the assessment findings for further instruction for the client