Examkin

Question

Difficulty: MediumBasic Care and Comfort

The nurse is caring for an 78-year-old client who recently experienced a cerebrovascular accident (CVA) resulting in right-sided facial weakness and dysphagia. Which of the following nursing interventions should the nurse include in the client's care plan to promote safe oral intake? Select all that apply.

  1. Encourage the client to use a chin-tuck technique while swallowing.Answer
  2. Place food on the left side of the client's mouth.Answer
  3. C
    Position the head of the bed at 30 degrees during mealtime to promote comfort.
  4. D
    Assign the unlicensed assistive personnel (UAP) to feed the client their first meal to evaluate tolerance.
  5. E
    Advise the family that frequent coughing during oral intake is a normal, expected age-related change.
  6. Maintain the client in an upright sitting position for at least 30 to 45 minutes after eating.Answer

Answer

The correct interventions are encouraging the chin-tuck technique, placing food on the unaffected (left) side of the mouth, and maintaining an upright position for 30 to 45 minutes post-meal.
The correct interventions focus on utilizing gravity, structural anatomy, and intact sensory-motor function to prevent aspiration. The chin-tuck narrows the airway, placing food on the unaffected left side maximizes chewing control, and remaining upright post-meal prevents regurgitation.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is 78 years old with a recent CVA, right-sided facial weakness, and dysphagia.
Identifying the specific neurological deficits determines the necessary aspiration precautions and feeding modifications.
2
Evaluate each intervention against standard aspiration precautions.
Interventions that protect the airway (chin-tuck, upright positioning) and utilize intact neurological function (feeding on the left side) are appropriate.
The primary goal of basic care and comfort in dysphagia is safe nutrition while preventing aspiration pneumonia.
3
Identify contraindicated actions and incorrect assumptions.
Positioning too low, delegating initial assessment tasks, and dismissing pathological signs (coughing) as normal aging are unsafe practices.
Nursing care must adhere to safety standards regarding positioning, scope of practice for delegation, and recognizing abnormal physiological responses.

Key Concept

Dysphagia Management and Aspiration Precautions
Rate this question

Topics

Basic Care and Comfort

More questions from this topic