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 intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
Rationale
Correct answer: B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.