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 {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

A. It would not be appropriate to place the client on restraints as this would increase agitation and he is not violent.

B. The client may have a urinary tract infection (UTI) that is causing fever, hypotension, and confusion. Monitoring elimination can help assess the severity of the infection and the need for antibiotics.

C. Dimming the lights can help reduce sensory overload and agitation in the client.

A. A B. B C. C

Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

A. To best hear the closing of the aortic heart valve, the nurse should place the diaphragm of the stethoscope at the second intercostal space, right sternal border. This is also known as the aortic area.
B. This is the tricuspid region, and defects with the tricuspid valve will be best heard in this area.
C. This is the mitral region and murmurs due to defects in the mitral valve will be appreciated here

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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

A nurse is caring for a client in the intensive care unit. Exhibits Complete the following sentence by using the list of options. The nurse should first plan to dropdown and then dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

Explanation

A nurse is assessing a client's cardiovascular system. Identify where the nurse should place the diaphragm of the stethoscope to best hear the closing of the aortic heart valve. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

Correct Answer is {"xRanges":[141.765625,171.765625],"yRanges":[127.609375,157.609375]}

Explanation

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