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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Brushing teeth immediately after eating may exacerbate nausea, especially if the client is experiencing pregnancy-related nausea and vomiting.
B. Laying down for 30 minutes after meals may worsen nausea and reflux symptoms.
C. Drinking 12 oz of water with each meal may contribute to feelings of fullness and exacerbate nausea and vomiting.
D. Eating a dry carbohydrate before getting out of bed, such as crackers or dry toast, can help alleviate nausea and vomiting associated with pregnancy by providing a bland, easily digestible source of energy before the client starts moving in the morning.
Correct Answer is D,C,E,A,B
Explanation
D. Apply sterile gloves and place cleansing balls in antiseptic solution.
C. Lubricate the catheter and place fenestrated drape over perineum.
E. Cleanse the meatus with the dominant hand in a downward motion.
A. Insert the catheter until a flow of urine begins.
B. Attach prefilled syringe to indwelling catheter inflation hub.
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