Examkin

Question

Difficulty: HardBasic Care and Comfort

A nurse is caring for a client who recently experienced a right-hemisphere ischemic stroke. The client has developed left-sided hemiplegia, left homonymous hemianopsia, and mild dysphagia. Which of the following basic care interventions should the nurse implement during mealtime?

  1. A
    Place the client in a semi-Fowler's position at a 45-degree angle during and immediately after the meal.
  2. B
    Advise the client to tilt the head slightly backward when preparing to swallow liquids.
  3. C
    Assign an unlicensed assistive personnel (UAP) to assist the client with feeding during their first oral meal.
  4. Arrange all food items and eating utensils on the right side of the client's overbed table.Answer

Answer

Arrange all food items and eating utensils on the right side of the client's overbed table.
A right-hemisphere ischemic stroke frequently results in left homonymous hemianopsia, which is the loss of the left half of the visual field in both eyes. By deliberately placing the meal tray, food items, and utensils on the client's right side, the nurse ensures that all items fall within the client's intact visual field. This intervention prevents unilateral neglect, promotes client independence, and facilitates adequate nutritional intake.

Step-by-Step Solution

1
Analyze the specific neurological deficits resulting from a right-hemisphere stroke.
The client experiences left-sided hemiplegia (weakness) and left homonymous hemianopsia (loss of the left visual field in both eyes).
Identifying the affected side is crucial for determining how to position the client's environment and food.
2
Determine the impact of left homonymous hemianopsia on basic care and nutrition.
The client cannot see objects placed on their left side, leading to a high risk of unilateral neglect where they may ignore half of their meal.
Interventions must compensate for the visual deficit to promote independence and adequate nutritional intake.
3
Identify the appropriate environmental adaptation for this visual deficit.
Food, beverages, and utensils must be placed within the intact right visual field so the client can clearly see and access them.
This directly addresses the sensory deficit and ensures safe, independent feeding.
4
Evaluate the distractors regarding dysphagia protocols and delegation rules.
Dysphagia requires a high-Fowler's position (90 degrees) and a chin-tuck swallowing technique. Additionally, the RN cannot delegate the initial feeding assessment to a UAP.
Ruling out unsafe positioning, improper swallowing mechanics, and out-of-scope delegation confirms the correct intervention.

Key Concept

Basic Care and Comfort for Stroke Clients (Nutrition, Positioning, and Safety)
Rate this question

Topics

Basic Care and Comfort

More questions from this topic