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Zorluk: OrtaBasic Care and Comfort

A registered nurse is developing a care plan for an older adult client who is recovering from a recent cerebrovascular accident (stroke) and has been diagnosed with new-onset dysphagia. Which of the following actions should the nurse include in the client's mealtime plan of care?

  1. A
    Place the client in a semi-Fowler's position at a 30-degree angle to prevent fatigue during the meal.
  2. B
    Delegate the initial meal feeding and swallowing observation to the unlicensed assistive personnel (UAP).
  3. Instruct the client to gently tilt their chin downward toward their chest when swallowing each bite of food.Cevap
  4. D
    Reassure the family that occasional choking and pocketing of food are normal physiological changes of the aging process.

Cevap

Instruct the client to gently tilt their chin downward toward their chest when swallowing each bite of food.
The correct answer provides an evidence-based intervention to prevent aspiration. The chin-tuck maneuver (flexing the neck) mechanically narrows the airway opening and widens the esophageal opening, making it easier and safer for the client to swallow without aspirating food or liquids into the lungs.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client is an older adult with a recent stroke and new-onset dysphagia.
Identifying the neurological deficit highlights the client's high risk for aspiration during oral intake.
2
Evaluate the proposed interventions against evidence-based safety guidelines for dysphagia.
Positioning at 30 degrees, delegating the initial assessment, and ignoring symptoms as 'normal aging' all severely compromise client safety and violate core nursing principles.
Aspiration precautions mandate upright positioning (90 degrees), RN-level assessment for initial feedings, and active recognition of pathology.
3
Select the appropriate therapeutic intervention.
Teaching the client the chin-tuck maneuver is identified as the correct nursing action.
This specific technique anatomically protects the airway during the swallowing phase, directly promoting basic care and comfort.

Anahtar Kavram

Dysphagia Management and Aspiration Precautions
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Konular

Basic Care and Comfort

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