3. Following a head injury, a client has no cough or gag reflex. The correct nursing action for feeding this client is to:
3. Following a head injury, a client has no cough or gag reflex. The correct nursing action for feeding this client is to:
. Position the head of bed 90 degrees for meals.
. Give only solid foods.
. Give only thick liquids.
. Use a feeding tube.
Test-Taking Tip
Three options require oral intake. Only one option is different. Choose the option that is different.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
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Answer 1 is incorrect because having the elevated head reduces the risk of aspiration, but this client is not able to swallow and should not receive meals. Answer 2 is incorrect because solid food is easier to swallow than thin liquids, but this client is not able to swallow and should not have either. Answer 3 is incorrect because thick liquids are easier to swallow than thin liquids, but this client cannot swallow and should not have any liquids. Answer 4 is correct because this client is at great risk for aspiration. The feeding tube bypasses the junction of the esophagus and trachea, where the aspiration could most likely occur.