Level: Clinical
Difficulty: Medium
Subtopic: Enteral nutrition
NCLEX: A 58-year-old client after a stroke is being evaluated for nursing care related to enteral nutrition. Assessment…
Nutrition Basic Care and Comfort
Case Study
A 58-year-old client after a stroke is being evaluated for nursing care related to enteral nutrition. Assessment data include the client coughs when drinking thin liquids and has wet vocal quality after swallowing. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that coughs when drinking thin liquids and has wet vocal quality after swallowing.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that coughs when drinking thin liquids and has wet vocal quality after swallowing.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that coughs when drinking thin liquids and has wet vocal quality after swallowing.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.