HESI Altered Nutrition

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.

1. In developing the nursing plan of care, which problem has the highest priority?

A. Aspiration
B. Skin Breakdown
C. Altered nutrition
D. Self care deficit

A. 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 in establishing the client’s plan of care.

NURSING PROCESS
2. After establishing priorities, what action should the nurse take next in developing Mrs. Rusk’s plan of care?

A. Analyze data
B. Establish goals
C. Complete an assessment
D. Implement interventions

B. Establish goals

Rationale: the nurse should first complete assessment, then analyze data to identify problems, and then establish goals. After 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

INTERPROFESSIONAL COLLABORATION
In developing the plan of care, the nurse recognizes that Mrs. Rusk’s dysphagia may impact her fluid and nutritional status.

3.The nurse plans interventions related to Mrs. Rusk’s dysphagia. Which member of the interdisciplinary team should the nurse refer Mrs. Rusk?

A. Case manager
B. Speech therapist
C. Registered dietician
D. Geriatric nurse practitioner

B. Speech therapist –

Rationale: Speech therapists have expertise in the evaluation and management of clients with dysphagia.

INTERPROFESSIONAL COLLABORATION
The nurse recognizes that Mrs. Rusk’s right-sided weakness is also a factor contributing to her risk for altered nutrition.

4. With which member of the interdisciplinary team should the nurse consult regarding this problem?

A. Bariatrics specialist
B. Clinical nutritionist
C. Occupational therapist
D. Rehabilitation counselor

C. Occupational therapist –

Rationale: Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self care.

DYSPHAGIA PRECAUTIONS
The speech therapist is consulted and makes a home visit to evaluate Mrs. Rusk. The therapist determines that dysphagia precautions are needed. The nurse and unlicensed assistive personnel (UAP) arrives at the home shortly after the therapist’s evaluation is completed. The UAP prepares to assist Mrs. Rusk with her noon meal and with her personal care.

5. What instruction should the nurse provide the UAP?

A. Keep the client in a semi-Fowler’s position while bathing her and also while assisting her with her meal
B. Help feed the client first and then allow her to rest with the head of the bed lowered for 1 hour before bathing her
C. Provide assistance with the meal and then lower the head of the bed to bathe the client and change the bed linens
D. Bathe the client first and then place the client in a high Fowler’s position during and after the meal.

D. Bathe the client first and then place the client in a high Fowler’s position during and after the meal –

Rationale: The head of the bed should be elevated to a high Fowler’s position while the client with dysphagia is eating, and kept elevated for at least 1 hour following the meal to reduce the risk for aspiration

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DYSPHAGIA PRECAUTIONS
The nurse visits with Mr. Rusk and then observes as the UAP assists Mrs. Rusk with her meal. The UAP gives Mrs. Rusk a glass of iced tea to drink.

6. Considering the need for dysphagia precautions, how should the nurse intervene?

A. Remind the IAP to keep track of the fluid intake and output
B. Advise the UAP to provide all fluids at room temperature
C. Instruct the UAP to add a thickening agent to all liquids
D. Establish a fluid restriction for the UAP to follow

C. Instruct the UAP to add a thickening agent to all liquids –

Rationale: Clients with dysphagia typically have difficulty swallowing liquids, so a thickening agent is aded to liquids to change the consistency, making swallowing easier.

NUTRITIONAL ASSESSMENT
During a home visit a week later, the nurse assesses Mrs. Rusk’s nutritional status.

7. Which data indicates the need for the nurse to evaluate Mrs. Rusk further for altered nutrition? (Select all the apply.)

A. The conjunctival sac is pale in appearance when exposed
B. Blanching occurs when the fingernail bed is compressed
C. The skin over the sternum tents when pinched
D. Bowel sounds are auscultated every 5 seconds
E. The lips are dry and cracked

A. The conjunctival sac is pale in appearance when exposed –
Rationale: The conjunctival sac should be dark pink. Pallor of any mucous membranes may indicate anemia.

C. The skin over the sternum tents when pinched –
Rationale: This is an unexpected finding. Skin tenting typically indicates a fluid volume deficit.

E. The lips are dry and cracked –
Rationale: This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration.

NUTRITIONAL ASSESSMENT
The nurse obtains further data regarding Mrs. Rusk’s nutritional status.

8. Which data best assesses the client’s functional ability related to nutrition?

A. Amount of groceries the client has in the home
B. Types of food the client has eaten within the last 24 hours
C. The client’s ability to feed herself with her left hand
D. The husband’s schedule for preparing meals

C. The client’s ability to feed herself with her left hand –

Rationale: This assessment provides information about the client’s functional ability.

NUTRITIONAL ASSESSMENT
9. In planning care, which intervention should be included to provide the nurse with the most accurate information regarding Mrs. Rusk’s ongoing nutritional status?

A. Instruct the home health aide to weigh the client once a week
B. Obtain a prescription to draw a complete blood count weekly
C. Teach Mrs. Rusk how to measure and record her abdominal girth every day
D. Advice Mr. Rusk to perform capillary glucose measurements before every meal

A. Instruct the home health aide to weigh the client once a week –

Rationale: Regular measurement of the client’s weight provides a useful measurement of 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.

NUTRITIONAL INTAKE
Two weeks later, the nurse notes a change in Mrs. Rusk’s weight. The nurse consults with the nutritionist, who helps complete a 24-hour calorie count. The nutritionist reports to the nurse that Mrs. Rusk, who weights 125 pounds and is 67 inches tall, is consuming 800 calories per day.

10. How should the nurse explain the results of the calorie count to Mr. and Mrs. Rusk?

A. Mrs. Rusk is taking in more calories than she needs and may gain weight
B. Mrs. Rusk is consuming an adequate number of calories for her height
C. Mrs. Rusk’s calorie consumption is insufficient and will result in weight loss
D. Since Mrs. Rusk’s activity is limited, her caloric intake is sufficient to meet her needs

C. Mrs Rusk’s calorie consumption is insufficient and will result in weight loss –

Rationale: An average adult requires 20 to 35 calories per kilogram per day. Mrs. Rusk, who weights 125 pounds, or 57 kilograms, needs a minimum of 1140 calories per day to maintain her current weight.

NUTRITIONAL INTAKE
11. Before notifying the health care provider of the data reported by the nutritionist, what information is most important for the nurse to obtain?

A. Type of vitamin supplement the client is taking
B. Percent of diet composed of carbohydrates
C. The clients calculated body mass index
D. Daily fat gram intake by the client

C. The client’s calculated body mass index –

Rationale: 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.

NUTRITIONAL INTAKE
The nurse reports the data about Mrs. Rusk’s nutritional status to the health care provider, who asks the nurse to obtain a blood sample for several lab tests. The nurse obtains a copy of the lab results the next day.

12. Which serum lab value reflects Mrs. Rusk’s altered nutrition?

A. Sodium of 144 mEq/L
B. Calcium of 9.5 mg/dl
C. Potassium of 3.8 mEq/L
D. Protein of 5.0 g/dl

D. Protein of 5.0 g/dl –

Rationale: The range for normal serum protein level in an adult is 6.4-8.3 g/dl. A level of 5.0 g/dl is low, and may be an indicator of malnutrition.

DIETARY INSTRUCTION
The health care provider prescribes an appetite stimulant and asks the nutritionist to consult with the Rusks regarding Mrs. Rusk’s dietary needs.
The nurse and nutritionist collaborate to develop a plan of care to improve Mrs. Rusk’s nutritional status. The nurse teaches the Rusks about foods high in protein and provides them with sample menus.

13. Which breakfast selection provides the most protein?

A. Oatmeal with a sliced banana
B. Pancakes with maple syrup
C. Hash browns and an English muffin
D. Scrambled eggs and sausage
E. Egg, potato and onion omelet

D. Scrambled eggs and sausage –

Rationale: Both eggs and sausage are good sources of protein

E. egg, potato, & onion omelet- good source of protein, vitamins and minerals

DIETARY INSTRUCTION
The nurse also encourages Mrs. Rusk to prepare high calorie snacks for Mrs. Rusk. Mr. Rusk states that his wife loves applesauce and asks if this is a good snack choice.

14. How should the nurse respond?

A. Do no offer her applesauce because it does not provide very many calories
B. Processed foods such as applesauce are often very high in sodium
C. Provide applesauce since she likes it, along with higher calories snacks
D. Applesauce is an excellent source of nutrients and calories

C. Provide applesauce since she likes it, along with higher calorie snacks –

Rationale: 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 really high calorie snack, with snacks which contain more calories, best meets the needs of the client.

DIETARY INSTRUCTION
Mrs. Rusk has a new prescription for an appetite stimulant.

15. Before advising Mrs. Rusk when she should take the medication, the nurse should obtain what information about the drug?

A. Onset of action
B. Therapeutic index
C. Drug half life
D. Bioavailablity

A. Onset of action –

Rationale: 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.

DIETARY INSTRUCTION
Mr. Rusk looks at the newly prescribed medication, which is a brand name drug, and states, “Next time we fill this prescription, I hope we can get this in a generic form. Maybe it won’t be so expensive.”

16. How should the nurse respond?

A. “You shouldn’t worry about the cost of medications right now; you should purchase whatever your wife needs to get well.”
B. “Brand name medications are generally more effective than generic drugs, so they are worth the additional cost.”
C. “Brand name drugs and generic drugs are bioequivalent, so Mrs. Rusk can safely take either form of the medication.”
D. “Your pharmacist and health care provider can determine if there is a generic drug that is a safe alternative to the brand name drug.”

D. “Your pharmacist and health care provider can determine if there is a generic drug that is a safe alternative to the brand name drug.” –

Rationale: Although brand name and generic medications are bioequivalent, the inert ingredients may vary, sometimes resulting in differing effects. Therefore, the health care provider must approve the substitution of a generic form for a prescribed brand name medication.

ETHICAL-LEGAL CONSIDERATIONS
Mrs. rusk gradually weakens and is admitted to the nearby medical center. Her health care provider recommends the insertion of a feeding tube, by means of a percutaneous esophageal gastrostomy (PEG). Mrs. Rusk signs the consent form and the procedure is scheduled for the next day. That evening, the nurse notes that Mrs. Rusk’s medical record contains an advanced directive requesting that she not be resuscitated in the event of an arrest, which is confirmed in the prescriptions written by the health care provider. While conversing with Mr. and Mrs. Rusk, Mr. Rusk confirms that Mrs. rusk has asked that “no heroic measures be taken to save her life.”

17. What action should the nurse take?

A. Meet privately with Mrs. Rusk to discuss that a feeding tube can be considered a heroic means of keeping a client alive
B. Inform Mrs. Rusk that the instructions in her advanced directive cannot be followed if she has a feeding tube
C. Ask Mrs. Rusk why she wants to have a feeding tube inserted since she has an advanced directive requesting no heroic measures
D. Advice Mrs. Rusk that an identifying bracelet needs to be secured on her wrist in case an emergency occurs

D. Advise Mrs. Rusk that an identifying bracelet needs to be secured on her wrist in case an emergency occurs –

Rationale: An identifying wrist bracelet indicating that resuscitation should not be performed helps ensure that the client’s wishes are known and respected.

ETHICAL-LEGAL CONSIDERATIONS
The next morning, the nurse enters Mrs. Rusk’s room to prepare her to go to the procedure room. The nurse states that the procedure is scheduled in 30 minutes. Mrs. Rusk, who is still lethargic from her sleeping pill, tells the nurse she has changed her mind and does not want the procedure performed, stating she would rather just “go ahead and die.” Her husband is in the room, and is very upset by his wife’s comment.

18. What action should the nurse implement?

A. Provide the couple with privacy to discuss the decision
B. Continue to prepare the client for the scheduled procedure
C. Remind the client that the consent form is already signed
D. Ask the client’s husband if the procedure should be cancelled

A. Provide the couple with privacy to discuss the decision –

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

CARE OF CLIENT WITH FEEDING TUBE
Mrs. Rusk 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.

19. What initial action should the nurse implement?

A. Connect the Lactated Ringer’s Solution to the PEG tube at the prescribed rate
B. Prepare to infuse water slowly through the PEG tube for the first 8 hours
C. Call the dietary department and request immediate delivery of the feeding solution
D. Continue to monitor the client without infusing any solution through the PEG tube

D. 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 following PEG tube insertion.

CARE OF CLIENT WITH FEEDING TUBE
The nurse observes that the dressing around the PEG tube insertion site is intact, with a small amount of serasanguineous drainage.

20. What action should the nurse implement?

A. Apply pressure dressing over the initial dressing
B. Circle the amount of drainage on the initial dressing
C. Remove the dressing and apply a new sterile dressing
D. Notify the health care provider of the finding immediately

B. Circle the amount of drainage on the initial dressing –

Rationale: Circling this small amount of drainage allows the nurse to compare any changes in the amount of drainage at a later time.

FORMULA CALCULATION
The next day, the nurse initiates the feeding prescribed by health care provider. The prescription is for half strength formula to infuse at 40 ml/hour. The formula is available in 8 ounce cans. The nurse is preparing enough formula for 12 hours.

21. How many cans of formula will the nurse need? (Enter numerical value only. If rounding is necessary, round to the whole number.)

1 –

Rationale: The nurse needs a total volume of 480 ml (12 hours x 40ml/hour). The prescription is for half strength formula, so the volume of formula needed is 240 ml (480/2). An 8-ounce can of formula contains 240 ml (8 ounces x 30 ml/ounce). Therefore, only 1 can of formula is needed.

FORMULA CALCULATION
After infusing the half strength formula at 40 ml/hour for 6 hours, the nurse checks the clients residual volume and obtains 75 ml. The prescription for the formula states that the prescription should be increased by 10 ml/hour as long as the client’s residual volume is less that half the previously infused total volume.

22. What action should the nurse implement?

A. Decrease the rate of the formula to 30 ml/hour
B. Maintain the rate of the formula at 40 ml/hour
C. Increase the rate of the formula to 50 ml/ hour
D. Increase the rate of the formula to 75 ml/hour

C. Increase the rate of the formula to 50 ml/ hour –

Rationale: The client has received 240 ml during the previous 6 hours. Half of that volume is 120 ml. The residual volume obtained was 75 ml. so the rate of formula should be increased by 10 ml/hour to 50 ml/ hour.

CLIENT TEACHING
Over time, the continuous feeding is increased to 80 ml/hour and changed to full strength formula. The nurse plans to teach Mr. Rusk how to manage the continuous feeding when Mrs. Rusk is discharged.

23. Before beginning the teaching plan, what action is most important for the nurse to implement?

A. Ask about the couple’s financial resources
B. Learn Mrs. Rusk’s anticipated discharge date
C. Determine if Mr. Rusk feels ready to learn the skill
D. Obtain information about the couple’s educational level

C. Determine if Mr. Rusk feels ready to learn the skill –

Rationale: Readiness to learn is essential for effective teaching. If Mr. Rusk expresses a lack of readiness to learn, the nurse can obtain further data, such as information about financial resources, which may be impacting his readiness to learn.

CLIENT TEACHING
When the nurse demonstrates the use of the feeding equipment, Mr. Rusk looks away. The nurse observes that he is crying.

24. What action should the nurse implement?

A. Continue with the demonstration of the equipment while allowing Mr. Rusk time to control his emotions
B. Reassure Mr. Rusk that management of the feeding equipment while allowing Mr. Rusk time to control his emotions
C. Stop the demonstration and leave the room until Mr. Rusk states he is ready to continue with the teaching session
D. Acknowledge the stressful nature of the situation and ask Mr. Rusk if he feels ready to continue

D. Acknowledge the stressful nature of the situation and ask Mr. Rusk if he feels ready to continue –

Rationale: This is a therapeutic response, offering support and allowing Mr. Rusk to feel in control of the situation.

BOLUS FEEDING
The feedings are changed to bolus feeding 3 times a day. After receiving instruction, Mr. Rusk demonstrates correct ability to perform the skill and states he feels he can handle this responsibility. Mr. Rusk is discharged home and home health care services resume. During a home visit, the nurse observes Mr. Rusk as he administers a bolus feeding to Mr. Rusk, who is sitting upright in the bed. After checking the residual volume, Mr. Rusk pours the feeding into the syringe attached to the feeding tube. He then holds the syringe upright while the feeding enters the stomach.

25. In observing this procedure, what action should the nurse take?

A. Teach Mr. Rusk to lower the syringe to increase the speed of the feeding
B. Lower the head of the bed until the feeding has all drained from the syringe
C. Remind Mr. Rusk to check for residual again after the feeding has entered the stomach
D. Ensure that Mr. Rusk flushes the tubing with water after the syringe is empty of feeding

D. Ensure that Mr. Rusk flushes the tubing 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

BOLUS FEEDING
While Mr. Rusk administers the feeding, Mrs. Rusk tells the nurse that she has had 5 to 7 liquid diarrhea stools a day for the last 2 days.

26. What action should the nurse implement first?

A. Notify the health care provider of the diarrhea
B. Tell Mr. Rusk to hold the remaining feeding
C. Assess the elasticity of Mrs. Rusk’s skin
D. Auscultate for the presence of bowel sounds

1)B. Tell Mr. Rusk to hold the remaining feeding –

Rationale: Tube feedings may cause diarrhea. The nurse should first advice Mr. Rusk to hold the remaining feeding until further assessment is completed
2) D. Auscultate for the presence of bowel sounds
3) C. Assess the elasticity of Mrs. Rusk’s skin
4) A. Notify the health care provider of the diarrhea

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