Hesi RN Exit Proctored Exam
An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?
Explanation & Rationale
A. Assessing the client’s swallowing reflex is the priority because the client’s facial paralysis raises the risk of aspiration; it is essential to ensure safety before providing any fluids. B. Providing a straw does not address the underlying swallowing difficulty and could increase the risk of aspiration. C. Obtaining thickening powder is important for safety, but it should only be done after assessing the swallowing reflex to determine if the client can handle any fluids. D. Assisting the spouse in giving water could lead to aspiration, especially since the client has impaired swallowing abilities; assessment must come first.
🔒 Submit your answer to reveal
Your Progress
Correct0
Incorrect0
Skipped0
Accuracy0%