Scenario Bertha, Klein, who is 70-years-old, suffered a stroke a year ago. She remains weak, and she has right-side paralysis and dysphagia. Her Husband, Frank has been caring for her at home. A home health nurse visitsevery other day and the Kleins’ synagogue has been providing one meal a day. The Kleins’ daughter, Carol, lives several states away with her husband and their three children, who are ages 15, 8, and 3
1.Which assessment should be done immediately?
a.Determine Frank’s knowledge about feeding a dysphagic person.b.Auscultate Bertha’s lungs for adventitious breath sounds.c.Asses Bertha’s LOC with the mini-mental status exam. d.Determine Bertha’s ability to swallow liquids. The home health nurse reports the following assessment findings to the healthcare provider (HCP): oral temperature 102oF and diminished breath sounds with crackles in the right lung. The HCP admits Mr. Klein to the acute care facility with the diagnosis of aspiration pneumonia. Stage 1 Bertha was sitting upright while Frank fed her broth from chicken noodle soup. She started spitting out the broth and turning blue around her mouth. Frank stopped feeding her and patted her back forcefully.