Which of the following items on the tray should the nurse remove?

Choice A rationale

Increased hair growth is typically associated with hormonal imbalances, such as an excess of androgens, or certain medications, not generally with undernutrition. Adequate nutrition is essential for maintaining normal hair growth cycles. Nutritional deficiencies often lead to hair thinning or loss, rather than increased growth.

Choice B rationale

A sore, inflamed buccal cavity, also known as stomatitis or mucositis, can be a direct consequence of inadequate nutrition, particularly deficiencies in B vitamins, iron, and vitamin C. These nutrients are crucial for maintaining the health and integrity of the oral mucous membranes. Inflammation and soreness can make eating painful, further contributing to poor nutrient intake.

Choice C rationale

Adequate nutrient or food intake directly contradicts the nursing diagnosis of imbalanced nutrition, less than body requirements. This finding would indicate that the patient's nutritional needs are being met, and the diagnosis would be inaccurate. The presence of dysphagia suggests difficulty in achieving adequate intake.

Choice D rationale

A weight within 10% of ideal body weight suggests that the patient's nutritional status is likely adequate, not less than body requirements. While dysphagia can lead to weight loss, a weight within the normal range indicates that the patient has been able to maintain their weight despite potential swallowing difficulties.

Choice A rationale

A speech therapist specializes in diagnosing and treating swallowing disorders, such as dysphagia. They assess the client’s ability to swallow safely and provide interventions to improve swallowing techniques, including exercises and modifications to diet. Referral to a speech therapist is essential for managing dysphagia and preventing complications like aspiration pneumonia.

Choice B rationale

A respiratory therapist primarily deals with breathing problems and airway management, not swallowing difficulties. While respiratory therapists play a role in managing clients with respiratory distress, they do not specialize in dysphagia.

Choice C rationale

A dentist focuses on oral health, which is important for overall health, but they are not the appropriate specialist for managing dysphagia. While they may address oral conditions that could impact swallowing, dysphagia management requires the expertise of a speech therapist.

Choice D rationale

A physical therapist focuses on physical movement and rehabilitation. While physical therapy may assist in mobility and motor coordination, dysphagia management falls within the domain of a speech therapist, not a physical therapist.