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.
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Related Questions
Correct Answer is D
Explanation
A. Diminished bowel sounds are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.
B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.
C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.
D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.
Correct Answer is A
Explanation
A.
A. The priority action is to remove the client from the source of carbon monoxide poisoning, which in this case is the kerosene space heater. Taking the client outdoors will provide fresh air and reduce exposure to carbon monoxide.
B. Wrapping blankets around the client may further exacerbate the symptoms by trapping the carbon monoxide, worsening the client's condition.
C. While loosening the client's clothing may improve ventilation, it is not as effective as removing the client from the source of exposure.
D. Opening the client's windows may help improve ventilation, but it is not as effective as taking the client outdoors to reduce exposure to carbon monoxide.
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