Level: Advanced
Difficulty: Hard
Subtopic: Malnutrition screening
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to malnutrition scree…
Nutrition Basic Care and Comfort
Case Study
A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to malnutrition screening. Assessment data include the client coughs when drinking thin liquids and has wet vocal quality after swallowing. Which intervention best reduces the client's risk of complications?
Question
A. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
B. Restrict all movement without individualized assessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
B. Restrict all movement without individualized assessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
Rationale
Correct answer: A. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.