TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 13: Promoting Nutrition Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The patient has weakness of the left arm and hand after a stroke. Which is the best nursing
intervention to help maintain the patient’s self-esteem during feeding? a. Delegate feeding to nursing assistive personnel (NAP) to minimize food spillage. b. Encourage the patient to self-feed as much as possible. c. Ensure that foods are pureed so they may be consumed through a straw. d. Collaborate with speech therapist to improve the patient’s nutrition. ANS: B
The nurse maintains and enhances the patient’s self-esteem by encouraging the patient with positive reinforcement, acknowledging the patient’s progress with self-feeding, and engaging him or her in conversation during feeding. Feeding the patient may reinforce feelings of inadequacy, worthlessness, or embarrassment. Taking food by straw may be contraindicated and increase the risk of aspiration, depending on the patient’s neuromuscular coordination for chewing and swallowing. The speech therapist can contribute to the patient’s nutritional status with specific feeding techniques, but this is not related to self-esteem. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
2. A patient has not eaten since admission to the long-term care facility 2 days ago. Which is the
best initial intervention for the nurse to prevent malnutrition in this patient? N a. Make a diet request to the health care provider for full liquids. b. Ask the patient’s daughter why the patient will not eat. c. Remind the patient that nutrition is essential to better health. d. Assess the patient for possible reasons for the lack of intake. ANS: D
The nurse gathers additional information by using the nursing process to prevent malnutrition for a new patient in the long-term care facility. Identifying barriers to nutrition begins with obtaining objective and subjective data by which the nurse gathers valuable nutritional information, including muscle function, teeth, cognition, and patient food preferences. Requesting a diet change is premature and not based on assessment data. Asking the daughter for information reveals the daughter’s opinion, anecdotal information, and possibly biased observations about the patient. The use of the word “why” is also not therapeutic. Reminding the patient about nutrition may be a useless intervention if his or her cognition is low, if he or she has a sensory or communication disorder, or if he or she is depressed. In addition, the patient can interpret this as an insult to his or her intelligence. DIF: Cognitive Level: Applying TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
3. A patient with a neurological disease has difficulty swallowing. Which does the nurse include
in the plan of care? a. Limit oral intake to clear liquids. b. Allow adequate time for the feeding.
TESTBANKWORLD.ORG
