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 A

Explanation

A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.

B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.

C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.

D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.

A. Administer an antitoxin. B. Quarantine the client. C. Monitor the client for a productive cough. D. Begin prophylactic treatment with ciprofloxacin.

Correct Answer is D

Explanation

A. Administer an antitoxin: There is no specific antitoxin available for anthrax. Treatment primarily involves antibiotics and supportive care.

B. Quarantine the client: Quarantine may not be necessary unless the client is confirmed to have an active infection or poses a risk of spreading the disease to others.

C. Monitor the client for a productive cough: While respiratory symptoms can occur in inhalation anthrax, monitoring for a productive cough alone may not be sufficient for management.

D. Begin prophylactic treatment with ciprofloxacin: Prophylactic antibiotic treatment with ciprofloxacin or doxycycline is recommended following exposure to anthrax to prevent the development of the disease.

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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 in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture?

Correct Answer is A

Explanation

A nurse is caring for a client following a possible exposure to anthrax. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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