Author Question: The patient is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis ... (Read 27 times)

danielfitts88 · **on:** Jul 22, 2018

The patient is assessed by the nurse as having a high risk for aspiration. The nursing diagnosis identified for the patient is Self-care deficit, feeding related to unilateral weakness.

Which of the following is an appropriate technique for the nurse to use when assisting this patient with feeding? a. Place food to the unaffected side of the mouth.
b. Place the patient in semi-Fowler's position.
c. Have the patient use a straw.
d. Use thinner liquids.

Question 2

When modifying a care plan to meet a client whose status has changed significantly over the past few days, what should the nurse do?

a. Redevelop the entire client care plan.
b. Focus on changing the nursing diagnoses and goals.
c. Perform a complete reassessment of all client factors.
d. Add more nursing interventions from a standardized plan of care.

Kimmy · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A

Feedback
A If the patient has unilateral weakness, the nurse should place food in the stronger side of the mouth.
B The patient should be positioned in an upright, seated position to prevent aspiration.
C Patients with unilateral weakness often have difficulty using a straw.
D Thickened liquids are often tolerated better and will help prevent aspiration, as patients with impaired swallowing often choke more with thin liquids.

Answer to Question 2

C

Feedback
A Reassessment may not require redoing the entire care plan.
B The nurse should not focus only on the nursing diagnoses and goals that have changed; nursing interventions may also need revising to meet new goals. Adding more nursing interventions may or may not be necessary. The nurse adjusts interventions on the basis of the client's response and the nurse's previous experience with similar clients.
C A complete reassessment of all client factors relating to the nursing diagnosis and etiology is necessary when modifying a plan. After reassessment, the nurse will determine what components of the care plan are accurate for the situation.
D Standards of care are used to determine whether the right interventions have been chosen or whether additional ones are required.