The nurse receives a client with malnutrition who had a cerebrovascular accident (CVA) 2 months ago with left hemiparesis. Rank the nursing tasks in order of importance beginning with the most important task

Question

1. Develop goals for client care.
2. Perform nutritional screening.
3. Advance diet to thicker foods.
4. Activate the suction apparatus.

Answer 1

4, 2, 1, 3
4. A major aspect of caring for a client with left hemiparesis is adapting activities of daily living to muscle weakness and uncoordinated neuromuscular function that can lead to impaired feeding, chewing, and swallowing and difficulty with food prepara-tion; thus, the nurse plans comprehensive care on the basis of client needs and the nursing process. The client's priority need is airway maintenance; to protect the air-way, the nurse needs to eliminate dysphagia as a contributor to the client's malnutri-tion because of the risks of aspiration, choking, and airway obstruction. To prevent complications of dysphagia, the nurse activates suction to clear the airway in an emergency.
2. Before planning additional nursing actions, the nurse collaborates on a nutritional assessment including a nutritional screening to identify altered eating patterns, food choices, and swallowing ability.
1. After data gathering, the nurse proceeds with the nursing process and develops nursing diagnoses, client outcomes, and client goals for nursing care.
3. After diagnosis and planning, the nurse implements the plan including advancing the diet and evaluating the client response to implement effective nursing care of a malnourished client.