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 A
Explanation
A.
A. Ventrogluteal - The ventrogluteal site is preferred for intramuscular injections in adults due to its proximity to large, deep muscles and minimal risk of injury to major nerves and blood vessels.
B. Dorsogluteal - The dorsogluteal site is not recommended for intramuscular injections due to the risk of injury to the sciatic nerve and superior gluteal artery.
C. Vastus lateralis - The vastus lateralis is a safe site for intramuscular injections, particularly in infants and young children.
D. Rectus femoris - The rectus femoris muscle is not typically used for intramuscular injections due to its superficial location and proximity to major blood vessels.
Correct Answer is D
Explanation
A. Brushing teeth immediately after eating may exacerbate nausea in some individuals. It is recommended to wait a while after eating before brushing teeth, or rinse the mouth with water.
B. Lying down after meals can worsen symptoms of nausea and reflux. Remaining upright or sitting up after meals may help alleviate symptoms.
C. Drinking large amounts of water with meals may exacerbate feelings of fullness and contribute to nausea. Sipping small amounts of fluids between meals is recommended.
D. Eating a dry carbohydrate, such as crackers or toast, before getting out of bed can help alleviate morning sickness by stabilizing blood sugar levels and absorbing stomach acid.
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