A nurse is assessing an older adult's nutritional status. The nurse understands that which of the following is the most important indicator for a potential nutritional deficit?

A. Right to visitation from others except legal advisors, who must obtain permission from the nursing facility before visiting the older adult

Explanation: The right to receive visitors is generally protected, with some reasonable restrictions, to ensure the safety and well-being of residents.

B. Right to be free from restraints

Explanation: Residents have the right to be free from unnecessary physical or chemical restraints, as outlined in their Bill of Rights. Restraints should only be used when necessary for the safety of the resident or others, and their use should be minimized.

C. Right to have a say in their care and treatment

Explanation: Residents have the right to actively participate in decisions about their care and treatment. This includes being informed about their options and having the opportunity to express their preferences.

D. Right to voice grievances

Explanation: Residents have the right to voice complaints or grievances without fear of retaliation. The nursing home must have a system in place to address and resolve residents' concerns.

E. "Right to information about their health but not about their medications" is not accurate. Residents have the right to be informed about all aspects of their health, including information about medications prescribed to them. Information about medications is an important component of informed consent and shared decision-making.

F. Right to be free from abuse

Explanation: Residents have the right to be free from any form of abuse, whether it is physical, verbal, psychological, or any other form. Nursing homes must take measures to prevent and address any instances of abuse.

A. Stroke under the chin in a downward motion.
Explanation: Stroking under the chin in a downward motion is not considered a standard technique for managing dysphagia. It's important to focus on strategies that promote safe swallowing and prevent aspiration.

B. Keep pulse oximeter ready at all times.
Explanation: While monitoring oxygen saturation is important in certain situations, having a pulse oximeter ready at all times may not be a routine instruction for feeding a client with dysphagia. Monitoring for signs of distress and ensuring a safe feeding environment are key aspects of care.

C. Avoid rushing the client or force feeding her.
Explanation: Rushing or force-feeding a client with dysphagia can increase the risk of aspiration. It's important to allow the client to eat at their own pace and take adequate time to chew and swallow safely.

D. If facial weakness is present, place food on the impaired side of the mouth.
Explanation: Placing food on the impaired side of the mouth can help compensate for facial weakness and promote more effective chewing and swallowing.

E. Alternate solid and liquid boluses.
Explanation: Alternating solid and liquid boluses can help with the overall coordination of the swallowing process. It can also facilitate the movement of food and liquids through the digestive tract.

F. Have the client sit at 90 degrees during all of oral intake.
Explanation: Ensuring that the client sits at a 90-degree angle during oral intake helps promote an upright position that aids in swallowing and reduces the risk of aspiration.