Altered Nutrition
Altered Nutrition
1. Nursing Process
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.
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 client's plan of care.
B. Skin breakdown.
This problem is important, but does not have the highest priority when developing the client's plan of care.
C. Altered nutrition.
This problem is important, but does not have the highest priority when developing the client's plan of care.
D. Self care deficit.
This problem is important, but does not have the highest priority when developing the client's plan of care.
3. 2.
After establishing priorities, what action should the nurse take next in developing Mrs. Rusk's plan of care?
A. Analyze data.
The data is analyzed prior to identifying the problems.
B. Correct Establish goals.
The nurse should first complete the assessment, analyze 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.
C. Complete an assessment.
The assessment is completed prior to identifying the problems.
D. Implement interventions.
Another step should be completed before implementing interventions. This step will come after goals are set.
1. Interdisciplinary Collaboration
In developing the plan of care, the nurse recognizes that Mrs. Rusk's dysphagia may impact her fluid and nutritional status.
2. 3.
The nurse plans interventions related to Mrs. Rusk's dysphagia. Which member of the interdisciplinary team
1. Nursing Process
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.
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 client's plan of care.
B. Skin breakdown.
This problem is important, but does not have the highest priority when developing the client's plan of care.
C. Altered nutrition.
This problem is important, but does not have the highest priority when developing the client's plan of care.
D. Self care deficit.
This problem is important, but does not have the highest priority when developing the client's plan of care.
3. 2.
After establishing priorities, what action should the nurse take next in developing Mrs. Rusk's plan of care?
A. Analyze data.
The data is analyzed prior to identifying the problems.
B. Correct Establish goals.
The nurse should first complete the assessment, analyze 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.
C. Complete an assessment.
The assessment is completed prior to identifying the problems.
D. Implement interventions.
Another step should be completed before implementing interventions. This step will come after goals are set.
1. Interdisciplinary Collaboration
In developing the plan of care, the nurse recognizes that Mrs. Rusk's dysphagia may impact her fluid and nutritional status.
2. 3.
The nurse plans interventions related to Mrs. Rusk's dysphagia. Which member of the interdisciplinary team