# A nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who has been experiencing progressive muscle weakness and difficulty swallowing. Which nursing intervention should be the highest priority to ensure client safety? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541222 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who has been experiencing progressive muscle weakness and difficulty swallowing. Which nursing intervention should be the highest priority to ensure client safety? ## 보기 1. Encourage the client to eat larger meals less frequently to reduce aspiration risk 2. Position the client upright at 90 degrees during meals and remain with the client throughout eating **✔ 정답** 3. Provide only liquid nutrition supplements to make swallowing easier 4. Allow the client to eat independently to maintain dignity and autonomy **정답: 2** ## 해설 Positioning upright at 90 degrees during meals with supervision is critical to prevent aspiration pneumonia, a leading cause of death in ALS patients with dysphagia. Other options do not address immediate safety risks as effectively. ## 심화 해설 Understanding the Priority: Airway Protection in ALS The correct answer is to position the client upright at 90 degrees during meals and remain with the client throughout eating. For a client with amyotrophic lateral sclerosis (ALS), a condition involving progressive degeneration of both upper and lower motor neurons, the highest priority stems from the risk of dysphagia and its life-threatening complication, aspiration pneumonia [1,2]. The principle of airway, breathing, and circulation (ABCs) dictates that maintaining a patent airway is the most immediate safety concern. Positioning is a foundational, non-invasive intervention that directly modifies the swallowing mechanism to protect the airway. Physiological Rationale for Upright Positioning The neuromuscular degeneration in ALS weakens the muscles of mastication and the pharyngeal and esophageal phases of swallowing [1]. When a client is positioned at a 90-degree angle, gravity assists in directing the food bolus downward into the esophagus, reducing the risk of it pooling in the pharynx or spilling into the laryngeal vestibule. This position also maximizes the function of any remaining protective reflexes by aligning the airway and digestive tract optimally. Remaining with the client is equally critical, as it allows the nurse to monitor for subtle signs of aspiration, such as coughing, a wet vocal quality, or changes in respiratory pattern, and to intervene immediately with suctioning or the Heimlich maneuver if needed. This continuous presence is a direct application of safety guidelines for managing dysphagia in neurodegenerative conditions [2,3]. Analysis of Incorrect Options The other options fail to prioritize safety or are based on flawed clinical reasoning. Option 1, encouraging larger meals less frequently, is contraindicated. Fatigue is a significant factor in ALS-related dysphagia; muscle weakness worsens with prolonged effort. Large meals increase the duration of eating, leading to fatigue of the swallowing muscles, which paradoxically elevates the risk of aspiration. The standard recommendation is smaller, more frequent meals to conserve muscle strength . Option 3, providing only liquid nutrition, is an unsafe generalization. While thickened liquids are often easier to control than thin liquids for some patients, thin liquids can be easily aspirated, especially in clients with impaired pharyngeal sensation or motor control. A comprehensive swallowing assessment by a speech-language pathologist is required to determine the safest diet consistency, which may include modified solids and thickened liquids, not just nutritional supplements [2]. Option 4, allowing the client to eat independently to maintain autonomy, is a psychosocial need that, while important, is secondary to physiological safety. In a client with progressive muscle weakness and known difficulty swallowing, prioritizing autonomy over direct supervision during a high-risk activity like eating violates the fundamental nursing duty to ensure client safety . The ethical principle of non-maleficence requires the nurse to prevent the foreseeable harm of aspiration, even if it temporarily limits independence.References (research sources) - [1]Rehabilitation in Amyotrophic Lateral Sclerosis: Recommendations for Clinical Practice and Further Research.GuidelineGratzer A, Gdynia N, Sasse N, Beese R, Winterholler C, Bauer Y, Schröter C, Gdynia HJ. (2025) · DOI: 10.3390/jcm14238590 - [2]European Academy of Neurology (EAN) guideline on the management of amyotrophic lateral sclerosis in collaboration with European Reference Network for Neuromuscular Diseases (ERN EURO-NMD).GuidelineVan Damme P, Al-Chalabi A, Andersen PM, Chiò A, Couratier P, De Carvalho M, Hardiman O, Kuźma-Kozakiewicz M, Ludolph A, McDermott CJ, Mora JS, Petri S, Probyn K, Reviers E, Salachas F, Silani V, Tysnes OB, van den Berg LH, Villanueva G, Weber M. (2024) · DOI: 10.1111/ene.16264 ## 임상 시나리오 ALS Dysphagia: Safe Feeding ProtocolPrioritizing Airway Protection During Oral Intake Position the client strictly upright at 90 degrees (high Fowler’s) to utilize gravity for bolus transit and airway protection. The nurse must remain at the bedside throughout the entire meal. Monitor for subtle signs of silent aspiration: a wet, gurgly voice quality, watery eyes, or a change in respiratory rate. Do not rely solely on a cough reflex, which is often blunted in ALS. Modify diet textures per speech-language pathology (SLP) recommendations. Thin liquids are typically the highest risk; use nectar-thick or honey-thick consistencies as prescribed. CautionA chin-tuck maneuver alone does not replace upright positioning. Keep emergency suction equipment set up and functional at the bedside. Stop feeding immediately if the client exhibits fatigue or respiratory distress. ## 핵심 개념 - **Aspiration Pneumonia** — A life-threatening lung infection caused by inhaling food, liquid, or saliva into the airways, a primary concern in ALS-related dysphagia. - **Dysphagia** — Difficulty swallowing involving the oral, pharyngeal, or esophageal phases, commonly progressive in ALS due to motor neuron degeneration. - **ABC Priority** — The nursing triage framework prioritizing Airway, Breathing, and Circulation; airway protection is the most immediate safety intervention. - **90-Degree Upright Position** — A high Fowler's position that uses gravity to direct the food bolus into the esophagus, minimizing the risk of laryngeal penetration. - **Silent Aspiration** — Entry of material into the airway without overt signs like coughing, common in ALS, necessitating direct nurse observation during meals. ## 같은 주제 문제 - [A 65-year-old male client with amyotrophic lateral sclerosis (ALS) is being assessed by th…](https://mymerci.kr/pages/nclex_q.php?qn_id=541217) - [A nurse is assessing a 58-year-old client with amyotrophic lateral sclerosis (ALS). 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