A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.)
a. Contact Adult Protective Services or hospital social work.
b. Notify the provider that the client needs a tube feeding.
c. Perform and document results of a Braden Scale assessment.
d. Request a dietary consultation from the health care provider.
e. Suggest a high-protein oral supplement between meals.
ANS: C, D, E
Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the client's risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being abused or needs a feeding tube at this time.
You might also like to view...
The nurse has staged a pressure ulcer that has a shallow crater with a dry pink wound bed as a:
a. stage I b. stage II c. stage III d. stage IV
A nurse is preparing a client to undergo cardiac catheterization. What specific assessment should the nurse make before the procedure?
A. Ascertain if the client will require sedation. B. Ascertain if the client is able to roll side to side. C. Ascertain if the client has a history of diabetes mellitus. D. Ascertain if the client has allergies to iodine-containing substances.
A patient reports epigastric abdominal pain, nausea, and vomiting. The serum amylase level is 450 units/dL. For which health problem should the nurse plan care?
1. gastritis 2. malnutrition 3. pancreatitis 4. diverticulitis
A nursing instructor describes the use of outcomes potentially sensitive to nursing as which of the following?
A) Standardized data reflecting nursing activities B) Medical diagnosis thought to measure nursing C) Inverse relationship between nursing and outcomes D) Adverse outcomes directly related to nursing care