HESI: Altered Nutrition
The client's husband states that his wife loves applesauce and asks if this is a good snack choice. Which response by the nurse is best?
"Offer her applesauce since she likes it, along with higher calorie snacks." To improve the client's 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 meets the needs of the client.
The client's 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 a generic form. Maybe it won't be as expensive." How should the nurse respond?
"Your pharmacist and healthcare provider can determine if there is a generic drug that is a safe alternative to the brand name drug. Although brand name and generic medications are bioequivalent, the inert ingredients may vary, sometimes resulting in differing effects. Therefore, the healthcare provider must approve the substitution of a generic form for a prescribed brand name medication.
The client tells the nurse that she has had 5 to 7 liquid diarrhea stools a day for the last 2 days What is the sequence of nursing actions?
1. Tell the spouse to hold the remaining feeding. 2. Auscultate for the presence of bowel sounds. 3. Assess the elasticity of the client's skin. 4. Notify the HCP of the diarrhea.
The next day, the nurse initiates the feeding prescribed by the HCP. The prescription is for the formula to infuse at 30 mL/hour. The formula is available in 8-ounce cans. The nurse is preparing enough formula for 12 hours. How many cans of formula will the nurse need?
1.5 The nurse needs a total volume 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.
When the nurse demonstrates the use of the feeding equipment, the client's spouse looks away. The nurse observes that he is crying. Which action should the nurse implement?
Acknowledge the stressful nature of the situation and ask him if he feels ready to continue. This is a therapeutic response, offering support and allowing the spouse to feel in control of the situation.
The client gradually weakens and is admitted to the medical unit. Her HCP recommends the insertion of a feeding tube, by means of a percutaneous esophageal gastrostomy (PEG). She signs the consent form, and the procedure is scheduled for the next day. That evening, the nurse notes that the client's medical record contains an advance directive requesting that she 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 confirm that "no heroic measures be taken to save her life." What action should the nurse take to ensure the client's DNR status?
Advise the client that she will need to sign a form that will be placed in her chart and according to their protocol a wrist band will be placed on her identifying that she not be resuscitated. Order in the client's chart and an identifying wrist bracelet indicating that resuscitation should not be performed helps ensure that the client's wishes are known and respected.
A older client is discharged from the hospital to rehab after suffering a 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. The nurse's assessment findings include right-sided weakness, slurred speech, and dysphagia. The nurse identifies that the client is at high risk for several problems. Of the client problems addressed on the nursing plan of care, which is of the highest priority problem?
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.
The speech therapist is consulted to evaluate the client. The therapist determines that dysphagia precautions are needed and writes an order for pureed diet and honey thickened liquids. The nurse and the unlicensed assistive personnel (UAP) enter the client's room shortly after the therapist's evaluation is completed. The UAP prepares to assist client with her noon meal and with her personal care. What instruction should the nurse provide to the UAP?
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.
The nurse observes that the dressing around the PEG tube insertion site is intact, with a small amount of serosanguineous drainage. Which action should the nurse implement?
Circle the amount of drainage on the initial dressing. Circling this small amount of drainage allows the nurse to compare any changes in the amount of drainage at a later time.
Before notifying the healthcare provider of the data reported by the nutritionist, what information is most important for the nurse to obtain?
Client's calculated body mass index. The body mass index is calculated based on the client's height and weight and provides a picture of the client's current nutritional status regarding over- or under-nutrition.
After establishing priorities, the nurse should take which action next in developing the client's plan of care?
Establish outcomes. The nurse should first complete the assessment, then 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 then evaluated to determine if the expected outcomes were accomplished.
The couple discusses the decision together, and the client decides to have the procedure as scheduled. She is taken to the procedure room where a PEG tube is inserted. Following the surgery the client returns to her room following the insertion of the PEG tube. She has an IV of Lactated Ringer's Solution infusing at 50 mL/hour but does not have any feeding solution attached to the PEG tube. Which initial actions should the nurse implement?
Continue to monitor the client without infusing any solution through the PEG tube. Feeding supplements are typically initiated when bowel sounds are present, usually within 24 hours after PEG tube insertion.
Over time, the continuous feeding is increased to 80 mL/hour. The nurse plans to educate the client's 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?
Determine if the client and her husband feel ready to learn the skill. Readiness to learn is essential for effective teaching. If the client's husbanc expresses a lack of readiness to learn, other resources will have to be initiated before his wife is discharged home.
The feedings are changed to bolus feeding 3 times a day. After receiving instruction, the client's 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 healthcare services are initiated. During a home visit, the nurse observes the client's spouse administering a bolus feeding to the client, who is sitting upright in the bed. After checking the residual volume, he pours the feeding into the syringe attached to the feeding tube. He then holds the syringe upright while the feeding enters the stomach. In observing this procedure, which action should the nurse take?
Ensure that he flushes the tubing with water after the syringe is empty of feeding. Flushing the syringe and tubing with water reduces the risk for obstruction of the tubing.
A week later, the nurse notes a change in the client's weight. The nurse consults with the nutritionist, who helps complete a 24-hour calorie count. The nutritionist reports back to the nurse that the client, weighs 110 lbs (50 kg), is 67 in (170.2 cm) tall, and is consuming 700 calories per day. How should the nurse explain the results of the calorie count to the client and her spouse?
Her calorie consumption is insufficient and will result in weight loss. An average adult requires 20 to 35 calories per kilogram per day. The client, who weighs 110 pounds, (50 kg) kilograms, needs a minimum of 1000 calories per day to maintain her current weight.
After infusing the formula at 30 mL/hour for 6 hours, the nurse checks the client's residual volume and obtains 75 mL. The prescription for the formula states that the rate should be increased by 10 mL/hour as long as the client's residual volume is less than half the previously infused total volume. Which action should the nurse implement?
Increase the rate of the formula to 40 mL/hour. The client has received 180 mL during the previous 6 hours. Half of that volume is 90 mL (180/2). The residual volume obtained was 75 mL, so the rate of formula should be increased by 10 mL/hour to 40 mL/hour.
Considering the need for dysphagia precautions, what action should the nurse implement to intervene?
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.
Which intervention should be included in the plan of care to provide the nurse with the most accurate information regarding the client's ongoing nutritional status?
Instruct the UAP 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.
The nurse recognizes that the client's right-sided weakness is also a factor contributing to her risk for altered nutrition. With which member of the interprofessional team should the nurse consult regarding this problem?
Occupational therapist. Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self-care.
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?
Onset of action. The nurse should determine when the drug will start to take effect, so that the medication can be taken when the greatest therapeutic effect can be achieved.
The nurse reports the data about the client's nutritional status to the health care provider, who orders several lab tests. The nurse obtains a copy of the lab results the next day. Which serum lab value reflects altered nutrition?
Protein of 5.0 g/dL (50g/L). The range for normal serum protein level in an adult is 6.4 to 8.3 g/dL (64 to 83 g/L). A level of 5.0 g/dL (50 g/L) is low, and may be an indicator of malnutrition.
The next morning, the nurse enters the client's room to prepare her to go to the procedure room. The nurse states that the procedure is scheduled in 30 minutes. The client, who is lethargic, tells the nurse she has changed her mind and does not want the procedure performed, stating that she would rather just "go ahead and die." Her spouse is in the room, and he is very upset by her comment. Which action should the nurse implement regarding cancellation of the procedure?
Provide the couple with privacy to discuss the decision. The nurse must address the client's expressed desire to cancel the procedure. The nurse's initial actions should include allowing the couple privacy to discuss the decision, addressing any concerns of the client, and encouraging further communication.
The health care provider prescribes an appetite stimulant and asks the nutritionist to consult with the client and her family regarding her dietary needs. The nurse and nutritionist collaborate to develop a plan of care to improve the client's nutritional status. The nurse teaches the client and her spouse about foods that are high in protein and provides them with sample menus. Which breakfast selection(s) are good sources of protein?
Scrambled eggs and sausage. Both eggs and sausage are good sources of protein. Egg, potato and onion omelet. An egg, potato, and onion omelet is a good source of protein and also provides minerals and vitamins.
The nurse visits with the client's spouse and then observes as the unlicensed assistive personnel (UAP) assists the client with her meal. The UAP gives her a glass of iced tea to drink and the client begins to cough. The nurse recognizes that the client's dysphagia may impact her fluid and nutritional status. The nurse plans interventions related to the client's dysphagia. To which member of the interprofessional team should the nurse obtain a referral order?
Speech therapist. Speech therapists have expertise in the evaluation and management of clients with dysphagia.
The nurse obtains further data regarding the client's nutritional status. Which information is best to use for assessment of the client's functional ability related to nutrition?
The client's ability to feed herself with her left hand. This assessment provides information about the client's functional ability.
Three days later the nurse assesses the client's nutritional status. Which data indicates the need for the nurse to evaluate the client further for altered nutrition?
The conjunctival sac is pale in appearance when exposed. The conjunctival sac should be dark pink. Pallor of any mucous membranes may indicate anemia. The skin over the sternum tents when pinched. This is an unexpected finding. Skin tenting typically indicates a fluid volume deficit. The lips are dry and cracked. This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration.
