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Difficulty: EasyPhysiological Adaptation

During mealtime on the rehabilitation unit, a practical nurse observes a client with a recent stroke holding unchewed food inside their cheek. The client then produces a weak, gargling cough. Which immediate intervention should the nurse implement?

  1. A
    Offer the client a sip of water through a straw to assist with swallowing.
  2. B
    Document the swallowing difficulty and continue to monitor the meal closely.
  3. Stop the feeding process and help the client clear the retained food from their mouth.Answer
  4. D
    Recline the client's chair backward to help the food slide down the throat.

Answer

Stop the feeding process and help the client clear the retained food from their mouth.
The client's weak cough and pocketing of food are classic signs of dysphagia and indicate a high risk for aspiration. To ensure safety and protect the airway, the immediate priority is to cease the meal and remove the unchewed food from the mouth.

Step-by-Step Solution

1
Analyze the clinical cues: The client is pocketing food and exhibiting a weak, gargling cough after a stroke.
These symptoms strongly suggest dysphagia and a diminished ability to protect the airway.
Neurological deficits from a stroke frequently impair the cranial nerves needed for safe swallowing and coughing.
2
Apply the Airway, Breathing, Circulation (ABC) priority framework to the situation.
The presence of unchewed food and a weak cough represents an immediate threat to the client's airway.
Airway protection is always the absolute highest priority in acute nursing care.
3
Determine the most appropriate immediate intervention.
The nurse must halt further oral intake and manually assist in clearing the oral cavity.
Removing the physical obstruction eliminates the immediate risk of aspiration into the lungs.

Key Concept

Aspiration Prevention and Airway Management in Dysphagia
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Topics

Physiological Adaptation

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