A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?

The client tucks his chin while swallowing food.

The client sits upright in bed during meals.

The client pockets food on one side of his mouth.

The client has a cough reflex.

Answer and Explanation

The Correct Answer is C

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

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Correct Answer is B

Explanation

A. While a blood pressure of 156/90 mm Hg may be elevated, it is not necessarily an indication to withhold propranolol, which is commonly used to treat hypertension.

B. A pulse rate of 54/min suggests bradycardia, which is a potential side effect of propranolol and may warrant withholding the medication.

C. A potassium level of 5.2 mEq/L is within the normal range (3.5-5.0 mEq/L) and is not typically a reason to withhold propranolol.

D. A sodium level of 130 mEq/L is within the normal range (135-145 mEq/L) and is not typically a reason to withhold propranolol.

A. Herpes simplex virus (HSV) type 1 B. Hepatitis A C. Human papillomavirus (HPV) D. Pediculosis capitis

Correct Answer is B

Explanation

A. Herpes simplex virus (HSV) type 1 infection is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.

B. Hepatitis A is a reportable infectious disease to the CDC due to its potential for public health significance, particularly in outbreaks or clusters of cases.

C. Human papillomavirus (HPV) infection is not typically a reportable diagnosis to the CDC unless it is part of a larger study or surveillance effort.

D. Pediculosis capitis (head lice infestation) is not typically a reportable diagnosis to the CDC unless it is part of a larger outbreak or cluster of cases.

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A nurse is caring for a client who experienced a stroke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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