An elderly patient has been admitted with a suspected stroke.
The patient has facial paralysis and is unable to move the left side of their body.
Upon entering the room, the nurse observes the patient’s spouse attempting to give the patient a drink of water, but struggling.
What should the nurse’s next course of action be?

Choice A rationale

Assisting the spouse and carefully giving the patient small sips of water may seem like a compassionate action. However, it could potentially lead to aspiration if the patient’s swallowing reflex is compromised, which is common in stroke patients.

Choice B rationale

While obtaining thickening powder before providing any more fluids can help prevent aspiration in patients with dysphagia, it is not the immediate action the nurse should take. The nurse first needs to assess the patient’s swallowing reflex before deciding on the appropriate intervention.

Choice C rationale

The nurse should ask the spouse to stop and assess the patient’s swallowing reflex. This is the most immediate and appropriate action. Stroke patients often have impaired swallowing reflexes, which can lead to aspiration if not properly managed. By assessing the swallowing reflex, the nurse can determine the best course of action to ensure the patient’s safety.

Choice D rationale

Giving the spouse a straw to help facilitate the patient’s drinking is not the best course of action. Straws can increase the risk of aspiration in patients with impaired swallowing reflexes. The nurse should first assess the patient’s swallowing reflex before deciding on the appropriate intervention.