Which of these assessment findings would support the nursing diagnosis risk for aspiration in a patient with a cerebral vascular accident?
1. absence of interest in eating or drinking
2. eating only foods on one side of the tray
3. refusal to allow the nurse to assist with feeding
4. continuous clearing of the throat or coughing while eating
4
Rationale: Continuous clearing of the throat or coughing while eating or drinking indicates that food or fluids are entering the trachea or pooling in the back of the throat. The nurse needs to stop feeding when this is noted and speech therapy should be consulted for a swallowing exam. Absence of interest in eating and refusing to allow the nurse to assist with feeding indicates an altered mood, such as depression, related to an altered neurological or health status. Eating foods only on one side of a tray represents a sensory perceptual problem related to the stroke.
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