Examkin

Question

Difficulty: MediumBasic Care and Comfort

A client recovering from an ischemic stroke with left-sided hemiparesis and mild dysphagia is cleared to begin a soft oral diet. Which nursing action represents the safest approach to managing this client's nutritional intake?

  1. Instruct the client to flex the neck and tuck the chin downward toward the chest while swallowing.Answer
  2. B
    Delegate the administration of the client's first oral feeding to an experienced unlicensed assistive personnel (UAP).
  3. C
    Maintain the head of the client's bed at a 30-degree elevation during and immediately after the meal.
  4. D
    Inform the client's family that occasional coughing while eating is an expected physiological change of aging.

Answer

Instruct the client to flex the neck and tuck the chin downward toward the chest while swallowing.
The correct action is instructing the client to use the chin-tuck maneuver. Flexing the neck and tucking the chin downward toward the chest helps protect the airway by mechanically narrowing the laryngeal opening and widening the esophageal opening. This facilitates safer swallowing and directly reduces the risk of aspiration.

Step-by-Step Solution

1
Identify the client's clinical condition and primary risk.
The client has dysphagia following a stroke, placing them at high risk for aspiration during oral feeding.
Understanding the neurological deficit is required to implement appropriate basic care and comfort measures.
2
Evaluate the safety and physiological rationale of the proposed interventions.
The chin-tuck method is a standard, safe compensatory technique to mechanically protect the airway during swallowing.
Airway protection is the highest priority when initiating an oral diet in a client with compromised swallowing ability.

Key Concept

Dysphagia Management and Aspiration Precautions
Rate this question

Topics

Basic Care and Comfort

More questions from this topic