A nurse is caring for an older adult client who recently experienced a cerebrovascular accident (stroke), resulting in right-sided hemiparesis and dysphagia. Which of the following basic care and comfort interventions should the nurse implement? Select all that apply.
- Position the client in a high-Fowler's position during and for at least 30 minutes after meals.Answer
- Place food directly onto the unaffected left side of the client's mouth.Answer
- CInstruct the client to tilt their head backward when initiating a swallow.
- Check the affected side of the client's mouth for pocketed food after eating.Answer
- EReassure the family that mild, frequent coughing while eating is a normal age-related change.
- FKeep the client positioned primarily on their affected right side while resting to prevent pressure on the healthy side.
Answer
The correct interventions are placing the client in a high-Fowler's position, placing food on the unaffected left side, and checking the affected side for pocketed food.
The appropriate interventions directly address the client's right-sided weakness and swallowing difficulties. Sitting up at 90 degrees utilizes gravity for safe swallowing. Placing food on the unaffected (left) side uses the functional muscles for chewing. Checking the affected side for pocketed food prevents silent or delayed aspiration of hidden food particles.
Step-by-Step Solution
Key Concept
Basic care, comfort, and safety interventions for clients with hemiparesis and dysphagia include aspiration precautions (high-Fowler's, chin-tuck, checking for pocketing) and pressure injury prevention.