Physiological Integrity: Basic Care and Comfort-Nutrition
10. A client is admitted with a diagnosis of brain attack (stroke). A physician orders a diet as tolerated. Before feeding the client, a nurse should first:
Physiological Integrity: Basic Care and Comfort-Nutrition
10. A client is admitted with a diagnosis of brain attack (stroke). A physician orders a diet as tolerated. Before feeding the client, a nurse should first:
. Wait for a specific diet order.
. Elevate the head of the bed 30 degrees.
. Evaluate the client's swallow reflex.
. Delegate feeding to the nursing assistant.
Test-Taking Tip
Focus on a step of the nursing process: "evaluate" before any action (wait, elevate, delegate). Think client safety.
Content Area: Adult Health, Cardiovascular; Integrated Process: Nursing Process, Planning; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Basic Care and Comfort/Nutrition and Oral Hydration
Physiological Integrity: Basic Care and Comfort-Nutrition
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Answer 1 is incorrect because the RN can offer the client any preferred foods. Answer 2 is incorrect because this would not be the first nursing action. Answer 3 is correct because the client may be at risk for aspiration if the ability to swallow has been affected. Answer 4 is incorrect because the RN must assess the client and determine ability to swallow before delegating care.