Examkin

Question

Difficulty: MediumBasic Care and Comfort

A nurse is caring for an older adult client with advanced Parkinson's disease who is on aspiration precautions due to documented oropharyngeal dysphagia. The client frequently experiences fatigue and bilateral hand tremors during mealtimes. Which of the following is the most appropriate nursing intervention to promote safe nutritional intake?

  1. Instruct the client to flex their neck and tuck their chin downward toward the chest during each swallow.Answer
  2. B
    Elevate the head of the bed to a 30-degree semi-Fowler's position during mealtime to maximize client comfort.
  3. C
    Delegate the initial assessment of the client's swallowing ability during the meal to an unlicensed assistive personnel (UAP).
  4. D
    Reassure the client that coughing while eating is a normal physiological change expected with advanced age.

Answer

The most appropriate nursing intervention is to instruct the client to flex their neck and tuck their chin downward toward the chest during each swallow.
Instructing the client to use the chin-tuck maneuver is the correct intervention. Tucking the chin downward toward the chest while swallowing narrows the airway opening and helps prevent the aspiration of food or fluids into the trachea, which is a critical basic care measure for clients with dysphagia.

Step-by-Step Solution

1
Identify the client's primary clinical risk based on the scenario.
The client has Parkinson's disease, documented oropharyngeal dysphagia, and is on aspiration precautions.
Establishing the highest priority need (airway protection) guides the selection of the most appropriate intervention.
2
Evaluate the proposed positioning and feeding techniques for safety and effectiveness.
The chin-tuck maneuver is identified as an evidence-based method to protect the airway during oral intake.
Flexing the neck narrows the airway opening, widens the valleculae, and pushes the epiglottis posteriorly, which helps prevent food or liquid from entering the trachea.
3
Analyze the distractors for safety, delegation, and pathological evaluation errors.
Semi-Fowler's positioning, delegating initial swallowing assessments to a UAP, and dismissing pathological coughing as normal aging are identified as unsafe nursing practices.
Eliminating contraindicated actions ensures the selected intervention strictly promotes safe basic care and comfort.

Key Concept

Basic Care and Comfort - Dysphagia and Aspiration Precautions
Rate this question

Topics

Basic Care and Comfort

More questions from this topic