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.
CORRECT
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.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.
C) Altered nutrition.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.
D) Self care deficit.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.
2.
After establishing priorities, what action should the nurse take next in developing Mrs. Rusk's plan of care?
A) Analyze data.
INCORRECT
The data is analyzed prior to identifying the problems.
B) Establish goals.
CORRECT
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.
INCORRECT
The assessment is completed prior to identifying the problems.
D) Implement interventions.
INCORRECT
Another step should be completed before implementing interventions. This step will come after goals are set.
Interdisciplinary 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.
INCORRECT
The case manager often directs the overall care for clients, but does not have expertise in the specific management
of clients with dysphagia.
, B) Speech therapist.
CORRECT
Speech therapists have expertise in the evaluation and management of clients with dysphagia.
C) Registered dietician.
INCORRECT
The registered dietician has expertise in dietary management, but is not the best interdisciplinary team member to
evaluate and plan care for the client with dysphagia.
D) Geriatric nurse practitioner.
INCORRECT
The nurse practitioner has expertise in the overall management of the needs of the geriatric client, but is not the
best interdisciplinary team member to evaluate and plan care for the client with dysphagia.
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.
INCORRECT
Bariatrics is a field of health care which deals with the problems of clients who are overweight.
B) Clinical nutritionist.
INCORRECT
Nutritionists have expertise in dietary management.
C) Occupational therapist.
CORRECT
Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self care.
D) Rehabilitation counselor.
INCORRECT
Rehabilitation counselors have expertise in assisting clients manage and cope with their disabilities.
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) arrive 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.
INCORRECT
This positioning places the client at risk for aspiration.
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.
INCORRECT
This positioning places the client at risk for aspiration.
C) Provide assistance with the meal and then lower the head of the bed to bathe the client and change the bed
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.
CORRECT
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.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.
C) Altered nutrition.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.
D) Self care deficit.
INCORRECT
This problem is important, but does not have the highest priority when developing the client's plan of care.
2.
After establishing priorities, what action should the nurse take next in developing Mrs. Rusk's plan of care?
A) Analyze data.
INCORRECT
The data is analyzed prior to identifying the problems.
B) Establish goals.
CORRECT
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.
INCORRECT
The assessment is completed prior to identifying the problems.
D) Implement interventions.
INCORRECT
Another step should be completed before implementing interventions. This step will come after goals are set.
Interdisciplinary 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.
INCORRECT
The case manager often directs the overall care for clients, but does not have expertise in the specific management
of clients with dysphagia.
, B) Speech therapist.
CORRECT
Speech therapists have expertise in the evaluation and management of clients with dysphagia.
C) Registered dietician.
INCORRECT
The registered dietician has expertise in dietary management, but is not the best interdisciplinary team member to
evaluate and plan care for the client with dysphagia.
D) Geriatric nurse practitioner.
INCORRECT
The nurse practitioner has expertise in the overall management of the needs of the geriatric client, but is not the
best interdisciplinary team member to evaluate and plan care for the client with dysphagia.
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.
INCORRECT
Bariatrics is a field of health care which deals with the problems of clients who are overweight.
B) Clinical nutritionist.
INCORRECT
Nutritionists have expertise in dietary management.
C) Occupational therapist.
CORRECT
Occupational therapists have expertise in helping clients adapt fine motor movements for the provision of self care.
D) Rehabilitation counselor.
INCORRECT
Rehabilitation counselors have expertise in assisting clients manage and cope with their disabilities.
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) arrive 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.
INCORRECT
This positioning places the client at risk for aspiration.
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.
INCORRECT
This positioning places the client at risk for aspiration.
C) Provide assistance with the meal and then lower the head of the bed to bathe the client and change the bed
