Examkin

Question

Difficulty: MediumBasic Care and Comfort

A nurse is caring for an older adult client who has right-sided hemiparesis and dysphagia following a recent cerebrovascular accident. The speech-language pathologist has cleared the client to begin a pureed diet. Which nursing action is most appropriate to ensure the client's safety and comfort during meals?

  1. Position the client upright at a 90-degree angle and encourage a slight chin tuck when swallowing.Answer
  2. B
    Delegate the administration of the client's first oral meal and swallowing evaluation to an unlicensed assistive personnel (UAP).
  3. C
    Instruct the client to slightly extend their neck backward to help gravity pull the food down the esophagus.
  4. D
    Document any mild coughing during the meal as an expected physiological change associated with the aging process.

Answer

The correct answer emphasizes placing the client in an upright, 90-degree position and utilizing a chin-tuck maneuver during swallowing.
The correct answer emphasizes placing the client in an upright, 90-degree position (high-Fowler's) and utilizing a chin-tuck maneuver. This optimal positioning uses gravity to facilitate gastric emptying while the chin tuck physically narrows the airway opening, significantly reducing the risk of aspiration in clients with neurological swallowing deficits.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has right-sided hemiparesis and dysphagia (difficulty swallowing) post-stroke.
These deficits place the client at a high risk for aspiration during oral intake.
2
Identify the priority for basic care and comfort during feeding.
The primary goal is to provide nutrition safely by preventing food or liquid from entering the airway (trachea).
Aspiration can lead to life-threatening complications such as aspiration pneumonia.
3
Evaluate positioning and anatomical techniques.
Positioning the client in high-Fowler's (90 degrees) enlists gravity to move food into the stomach. The 'chin-tuck' maneuver narrows the airway opening.
This specific body and head positioning directs food safely down the esophagus and away from the trachea.
4
Select the safest nursing action.
Positioning the client upright with a chin tuck is the most appropriate, evidence-based intervention.
It directly addresses the physiological deficit while promoting safe nutritional intake.

Key Concept

Dysphagia feeding precautions and positioning to prevent aspiration.
Rate this question

Topics

Basic Care and Comfort

More questions from this topic