Level: Clinical
Difficulty: Medium
Subtopic: Dysphagia and aspiration risk
NCLEX: A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to dysphagia and aspi…
Nutrition Basic Care and Comfort
Case Study
A 79-year-old client on a medical-surgical unit is being evaluated for nursing care related to dysphagia and aspiration risk. Assessment data include the client receives enteral feeding and develops abdominal distention with nausea. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that receives enteral feeding and develops abdominal distention with nausea.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that receives enteral feeding and develops abdominal distention with nausea.
Rationale
Correct answer: D. The new finding that receives enteral feeding and develops abdominal distention with nausea.
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.