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?

Rationale: A. Give the spouse a straw to help facilitate the client's drinking: Using a straw can increase aspiration risk in clients with impaired swallowing or facial weakness. It promotes rapid fluid intake, bypassing normal protective reflexes. B. Assist the spouse and carefully give the client small sips of water: Offering fluids before assessing swallowing can be dangerous. Clients with possible CVA and facial paralysis are at high risk for aspiration pneumonia due to impaired gag and swallow reflexes. C. Ask the spouse to stop and assess the client's swallowing reflex: This is the safest and most appropriate action. A swallowing assessment helps determine aspiration risk before any oral intake is provided, especially in neurologically impaired clients. D. Obtain thickening powder before providing any more fluids: Thickened fluids may help prevent aspiration, but they should not be used before confirming the client’s ability to safely swallow. A full assessment is the priority first step.