For a client with a cerebrovascular accident, which of the following criteria must be fulfilled before the client is fed?

Appeared in: NIMHANS Nursing Officer - 2019

Explanation

A bedside swallow screen, which involves giving small sips of water, is the standard initial nursing assessment to check for dysphagia before feeding a post-stroke client.
The absence of coughing, choking, or a 'wet' gurgly voice after swallowing is a key indicator that the client may be able to tolerate oral intake safely.
This assessment is a critical patient safety measure to prevent aspiration pneumonia, a common and serious complication following a stroke.

Option B: The presence or absence of a gag reflex is not a reliable indicator of a safe swallow or airway protection.
Option C: Cranial nerves (CN) III (Oculomotor), IV (Trochlear), and VI (Abducens) are responsible for controlling eye movements, not swallowing.
Option D: Speech function (articulation) is distinct from swallowing function (deglutition), although they share some musculature. Normal speech is not a prerequisite for safe feeding.

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Assessment of swallowing function and aspiration risk in a post-stroke client as background academic context rather than a clinical decision trigger.
Nurses are on the frontline of preventing aspiration pneumonia. Failure to correctly identify dysphagia before feeding can lead to serious complications, including lung infection, malnutrition, and dehydration.
Any client who fails a bedside swallow screen must be kept NPO (nothing by mouth). The nurse's next action is to notify the healthcare provider and recommend a formal evaluation by a Speech-Language Pathologist (SLP).
What if? If the client has a tracheostomy tube, the cuff (if present) should be inflated during the swallow screen and feeding to provide an extra layer of protection against aspiration.

How to Approach the Question

First, identify the core safety issue in the question: feeding a stroke patient. The primary risk associated with this is aspiration.
Next, evaluate each option based on its direct relevance to assessing aspiration risk at the bedside.
Option A describes a direct functional test of swallowing (the water swallow test) and looks for a classic sign of aspiration (coughing).
Recognize that the gag reflex (Option B) is a common misconception and is not a reliable test for swallowing safety.
Eliminate Option C by recalling the functions of the cranial nerves; III, IV, and VI are for eye movement, not swallowing.
Differentiate between speech and swallowing functions to eliminate Option D.

Concept Tested & Keywords

Concept Tested: Assessment of swallowing function and aspiration risk in a post-stroke client.
Stem keywords: cerebrovascular accident, client is fed
Lead-in keywords: criteria must be fulfilled
Negative lead-in flag: false

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 71-73

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 213-215

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Attempt every question from this paper in a timed mock, then review the full solution for each one.