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Zorluk: KolayBasic Care and Comfort

An older adult client with generalized weakness and a history of mild dysphagia is about to receive their lunch tray. Which nursing action is most appropriate to promote safe swallowing and prevent aspiration?

  1. Elevate the head of the bed to a 90-degree angle during the meal and for at least 30 minutes afterward.Cevap
  2. B
    Encourage the client to extend their neck and tilt their head backward when swallowing liquids.
  3. C
    Document frequent coughing during the meal as a normal age-related change in the swallowing reflex.
  4. D
    Assign an unlicensed assistive personnel (UAP) to feed the client and monitor for signs of choking.

Cevap

The correct action is to elevate the head of the bed to a 90-degree angle during the meal and for at least 30 minutes afterward.
Elevating the head of the bed to a 90-degree angle (high-Fowler's position) is the most critical intervention for a client with dysphagia. This upright position utilizes gravity to help food and liquids travel down the esophagus and prevents gastric reflux. Maintaining this position for 30 to 45 minutes after the meal provides ongoing protection against delayed aspiration.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is an older adult with generalized weakness and a documented history of mild dysphagia.
Identifying the client's specific deficits highlights that they are at a high risk for aspiration during oral intake.
2
Identify the primary nursing goal for this procedure.
The primary goal during meal assistance is to promote safe swallowing and protect the airway.
Basic care and comfort must prioritize physiological safety, specifically preventing aspiration pneumonia.
3
Evaluate the proposed nursing interventions against safety standards.
Positioning the client upright at 90 degrees utilizes gravity to assist food transit and keeps the airway protected, whereas tilting the head back, ignoring coughing, or delegating to a UAP introduces severe safety risks.
Standard nursing guidelines require the high-Fowler's position during and immediately after meals for any client with swallowing difficulties.

Anahtar Kavram

Aspiration Precautions and Safe Feeding Techniques
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Konular

Basic Care and Comfort

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