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1. A older client is discharged from the hospital to rehab after suffering a
cerebral vascular accident (CVA) often referred to as a stroke. The client lives
with her spouse who is in good health. The rehab nurse enters the room to
assess the client.
Nursing Process
The nurse's assessment findings include right-sided weakness, slurred
speech, and dysphagia. The nurse identifies that the client is at high risk for
several problems.
Of the client problems addressed on the nursing plan of care, which is of the
highest priority problem?
-Aspiration.
-Skin breakdown.
-Altered nutrition.
-Self-care deficit.:
Answer:
-Aspiration.
Aspiration, or the entry of foreign substances such as food or fluids into the lungs,
may cause hypoxia or respiratory distress. Therefore, this is the highest priority in
establishing the client's plan of care.
2. After establishing priorities, the nurse should take which action next in
preventing the client from aspirating?
-Obtain a prescription for placement of enteral feeding tube.
-Elevate the head of head to 30 degrees.
-Ensure client participates with PT and OT exercises for strengthen.
-Ensure the client's meals are pureed.:
Answer:ÂÂ
2026 HESI Altered Nutrition Exam Questions and Answers, Complete Complete And Study material 11pages LEARNEXAMS
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