2024 HESI Altered Nutrition Exam Guaranteed A+ Actual Questions and Answers, Complete 100%

Document Content and Description Below

1. 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. T... he rehab nurse enters the room to assess the client. Nursing Process 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. -Skin breakdown. -Altered nutrition. -Self-care deficit.: Answer: -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. 2. After establishing priorities, the nurse should take which action next in preventing the client from aspirating? -Obtain a prescription for placement of enteral feeding tube. -Elevate the head of head to 30 degrees. -Ensure client participates with PT and OT exercises for strengthen. -Ensure the client's meals are pureed.: Answer: -Elevate the head of head to 30 degrees. Positioning the client with head of bed elevated will decrease the risk for aspiration. 3. The nurse visits with the client's spouse and then observes as the unlicensed assistive personnel (UAP) assists the client with their meal. The UAP gives the client 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. To which member of the interprofessional team should the nurse obtain a referral order? -Case manager. -Speech therapist. -Registered dietician. -Geriatric nurse practioner.: [Show More]

Last updated: 2 weeks ago

Preview 1 out of 11 pages