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Difficulty: MediumBasic Care and Comfort

A nurse is caring for an older adult client who has right-sided hemiplegia and severe dysphagia following a recent cerebrovascular accident. Which of the following actions should the nurse take when managing the client's nutritional intake?

  1. A
    Assign an unlicensed assistive personnel (UAP) to conduct the initial feeding to assess the client's tolerance.
  2. B
    Maintain the client in a semi-Fowler's position at a 45-degree angle during the meal.
  3. C
    Consider the client's occasional coughing during meals as a normal, age-related decline in the gag reflex.
  4. Direct small bites of food into the left side of the client's mouth to promote safe swallowing.Answer

Answer

The correct action is to direct small bites of food into the left side of the client's mouth.
The correct action is to place food on the left side of the client's mouth. The client has right-sided hemiplegia, which indicates weakness on the right side of the body and oral cavity. Placing food on the unaffected (stronger) side facilitates effective chewing, improves bolus control, and significantly decreases the risk of aspiration.

Step-by-Step Solution

1
Identify the client's specific physiological deficits based on the clinical scenario.
The client has right-sided hemiplegia and severe dysphagia, which means the musculature on the right side of the face and throat is weak and swallowing is compromised.
Understanding the precise anatomical and functional limitations dictates the necessary safety interventions for oral feeding.
2
Evaluate the proposed feeding interventions for safety and anatomical appropriateness.
Placing food on the left side utilizes the intact, stronger musculature on the unaffected side.
Using the strong side of the mouth maximizes chewing efficiency, provides better control of the food bolus, and minimizes the likelihood of aspiration.
3
Assess the remaining options against standards of care for positioning, delegation, and gerontology.
The other options violate principles of safe delegation, correct aspiration-prevention positioning, and the clinical distinction between pathology and normal aging.
The nurse must ensure all interventions align with evidence-based practice for dysphagia management to prevent life-threatening complications.

Key Concept

Dysphagia feeding precautions and aspiration prevention
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Topics

Basic Care and Comfort

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