A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?

A. Cleanse the wound with cotton balls – Cotton fibers can shed and leave debris in the wound, increasing the risk of infection. Gauze or irrigation is preferred.
B. Use a 10-mL syringe filled with cleansing solution – A 10-mL syringe does not provide sufficient pressure for effective irrigation. A 30- to 60-mL syringe is typically recommended.
C. Hold the syringe tip 2.5 cm (1 in) above the upper end of the wound – This ensures appropriate pressure and prevents contamination while effectively flushing out debris.
D. Dry the wound bed with gauze squares – The wound bed should be kept moist to promote healing; only the surrounding skin should be dried if necessary.

Rationale:

A. This response addresses the client's desire to have family visits but does not directly address the client's concerns about end-of-life care.

B. Asking the client to express their expectations about activities related to the end-of-life allows the nurse to understand the client's wishes and concerns and to provide appropriate support.

C. This response addresses the client's need for pain management but does not directly address the client's concerns about end-of-life care.

D. This response addresses the client's need for spiritual support but does not directly address the client's concerns about end-of-life care.