Question

After meals, the nurse must always check _______ of the CVA client for _________.

A) Blood pressure, hypertension

B) Respirations, dyspnea

C) Mouth, aspiration

D) Temperature, fever

Answer 1

The nurse must check the mouth of the CVA client for aspiration after meals to ensure that no food or liquid has entered the airway, which could cause serious complications.

Step-by-step explanation:

After meals, the nurse must always check the mouth of the CVA client for aspiration. This is important because clients with cerebrovascular accidents (stroke) may have difficulty swallowing, a condition known as dysphagia. This can lead to food or liquid entering the airway, which is known as aspiration, potentially causing aspiration pneumonia or other complications.

In the clinical scenario described, although John does not have a CVA, his symptoms such as coughing and shortness of breath could potentially be aggravated by aspiration, so monitoring for this in similar cases would also be important. Additionally, monitoring vital signs like blood pressure, respirations, and temperature would be part of a comprehensive assessment but not specifically for aspiration post meals in a CVA client.

Answer 2

The nurse should check the mouth of a CVA client after meals to look for signs of aspiration, which is a critical part of post-stroke care.

Step-by-step explanation:

After meals, the nurse must always check the mouth of the CVA client for aspiration. This is a crucial step in patient care for individuals who have experienced a cerebrovascular accident (CVA), commonly known as a stroke, as they may have difficulty swallowing (dysphagia) leading to the potential risk of food or liquid entering the lungs, which could cause aspiration pneumonia. Monitoring after meals can help prevent this serious complication.