Medical Surgical Stroke #4

Question

A client with dysphagia is at risk for aspiration. Which of the following instructions by the nurse is most important in helping with dysphagia after a stroke?

Answers

  1. Provide thin liquids until swallowing improves.
    • Rationale:

      This answer is not correct because after a stroke with dysphasia, the client may have increased risk of choking and aspiration with thin liquids. Liquids should therefore be thickened to avoid aspiration.

  2. Feed the client in bed until mobility improves.
    • Rationale:

      This answer is not correct because feeding the client in bed, limits client participation in daily activities, and the client should join others for meals if possible. Keeping a client in the bed may affect circulation, skin integrity, and psychosocial well being.

  3. Assist with meals and maintain clients in an upright position.
    • Rationale:

      This answer is correct because the client should be in the upright position to avoid aspiration during and after meals. In this position, gravity aids in normal flow of food into the digestive tract. Aspiration can occur when stomach contents enter the client’s lungs. This can cause airway obstruction, coughing, choking, decreased oxygenation, and can lead to aspiration pneumonia.

  4. Spoon-feed all meals to ensure the client can get enough nutrition.
    • Rationale:

      This answer is not correct because spoon-feeding is detrimental to self-dignity. The client should be encouraged to feed self and perform as many tasks as possible using the unaffected side.

Overview

Difficulty swallowing is the medical definition of dysphagia. Neurological damage can affect the ability of swallowing, therefore assistance with meals and maintaining the clients in an upright position is necessary.

Explanation

Learning Outcomes

Aspiration can occur when stomach contents enter the client’s lungs. This can cause airway obstruction, coughing, choking, decreased oxygenation, and can lead to aspiration pneumonia. Risk for aspiration is a nursing diagnosis for dysphagia. The risk of aspiration is higher with thin liquids than it is with thickened liquids. Placing the client in an upright, 90 degree angle during mealtime, and maintaining that position for approximately 45 minutes afterwards is a prime intervention. Assistance with meals is important so as to maintain safety for the client with dysphagia. However, dignity of risk is an important factor to consider. Encouraging the client to use the unaffected side to feed themselves is favorable in maintaining client’s dignity.

Test Taking Tip

Remember to always apply the prioritization of nursing ABC triage to determine the priority answer. Then, always consider Maslow’s Hierarchy of Needs when answering questions and caring for clients.

Video Rationale