A nurse is caring for a client who had a stroke and is experiencing dysphagia. Which of the following actions should the nurse take when assisting the client to eat?

Rationale
• Assist the client to the bathroom.
• Non-essential: The client’s current condition indicates severe changes, including a significant drop in consciousness and worsening vital signs. Immediate priorities involve stabilization and monitoring rather than assisting with bathroom needs.
• Initiate seizure precautions.
• Anticipated: The client’s deteriorating condition, including restlessness, agitation, and decreased level of consciousness, increases the risk of seizures. Initiating seizure precautions is appropriate to ensure safety.
• Record GCS every 15 min for the first 4 hr.
• Anticipated: The Glasgow Coma Scale (GCS) score of 9 indicates a significant decrease in consciousness. Frequent monitoring of GCS is crucial to assess changes in neurological status and to guide further intervention.
• Elevate the head of the bed.
• Anticipated: Elevating the head of the bed can help with cerebral perfusion and decrease intracranial pressure. This is a common intervention for clients with neurological issues to improve comfort and safety.
• Keep the client's head in midline position.
• Anticipated: Maintaining a midline position helps ensure optimal cerebral perfusion and reduces the risk of complications. It is particularly important in clients with neurological changes.
• Encourage the client to cough.
• Non-essential: Given the client's current level of consciousness and agitation, encouraging coughing might not be appropriate and could cause further distress or complications.
• Decrease oxygen to 1.5L/min via nasal cannula.
• Contraindicated: The client’s oxygen saturation has dropped to 90% despite receiving 6 L/min of oxygen. Decreasing the oxygen flow could further impair oxygenation. The priority is to maintain or increase oxygen levels to ensure adequate oxygenation.

A. Offer meals to the client following physical activity: This is incorrect as eating after physical activity might be challenging for a client with dysphagia, and it is better to provide meals when the client is at rest.
B. Provide peanut butter on crackers as a snack choice: This is incorrect because peanut butter and crackers might be difficult to swallow and could pose a choking risk for someone with dysphagia.
C. Provide liquids in a cup with a straw: This is incorrect as straws can cause liquids to be aspirated more easily, which is a risk for clients with dysphagia.
D. Instruct the client to tilt his head forward when swallowing: This is correct because tilting the head forward can help prevent aspiration and facilitate safer swallowing in clients with dysphagia.