A nurse is developing a plan of care for an 80-year-old client who has right-sided hemiplegia and dysphagia following a recent cerebrovascular accident (CVA). Which interventions should the nurse include in the client's plan of care to promote basic care, comfort, and safety? Select all that apply.
- Utilize a pressure-redistributing mattress and reposition the client at least every 2 hours.Cevap
- Perform oral hygiene using a moistened sponge swab and gentle suctioning.Cevap
- Maintain the client in a high Fowler's position during meals and for 30 minutes after eating.Cevap
- DPlace a rolled pillow directly under the client's knees while in bed to prevent sliding.
- EDelegate the feeding of the client's initial meal to the unlicensed assistive personnel (UAP).
- FRestrict the client's oral fluid intake to prevent episodes of expected age-related urinary incontinence.
Cevap
The correct interventions are utilizing a pressure-redistributing mattress, performing oral hygiene with a sponge swab and suction, and maintaining a high Fowler's position during and after meals.
Clients with hemiplegia and dysphagia require meticulous basic care to prevent life-threatening complications. A pressure-redistributing mattress and frequent repositioning are foundational to prevent skin breakdown in immobile clients. Proper oral hygiene using a moistened sponge swab with gentle suctioning minimizes the aspiration risk while maintaining mucosal integrity. A high Fowler's position (60 to 90 degrees) during meals and for at least 30 minutes afterward is essential; it utilizes gravity to facilitate swallowing and significantly reduces the risk of aspiration pneumonia.
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Basic Care, Comfort, and Safety for Stroke Survivors