The nurse prepares to administer medication to the client who is recovering from a closed head injury. Which does the nurse implement before administering oral medication to prevent client aspiration of gastric contents? (Select all that apply.)
1. Observe the client's intake of solid food.
2. Palpate swallowing at level of the larynx.
3. Ask client to swallow small sips of water.
4. Observe chest during mealtime for dysphagia.
5. Ask client to swallow and observe client's neck.
6. Evaluate for impaired chewing or tongue control.
2, 4, 6
2. The client with a closed head injury is at greater risk of a decreased level of con-sciousness and seizures, so the nurse carefully assesses the client before administering medications to avoid client aspiration and injury. The nurse palpates the client's larynx to evaluate swallowing and expects the larynx rise and fall.
4. The nurse observes the client's chest during mealtime for clinical indicators of dysphagia, coughing, and choking.
6. Chewing breaks food down to smaller, more manageable pieces for swallowing and the tongue pushes them to the back of the mouth. Impaired chewing and tongue control increase the risk of aspiration because they decrease client ability to alter foods mechanically for safe swallowing. If foods are swallowed with insufficient chewing, the client is more likely to choke and aspirate.
1 and 3. The nurse offers the client nothing by mouth until dysphagia is ruled out to avoid choking and coughing.
5. Meaningful evaluation of swallowing is not observable in the neck.
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