A nurse is caring for a client with dysphagia associated with a left-sided stroke and right-sided weakness.
Which of the following strategies are appropriate to reduce the risk of aspiration?

Encourage client to tuck chin when swallowing.

Ensure that any protein is pureed prior to feeding the client.

Assess client's preferences and have their family leave snacks at their bedside.

Turn on music to promote client's relaxation.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Chin tuck alters airway mechanics, reducing aspiration risk by improving epiglottic closure and minimizing passage of food into respiratory pathways.

Choice B rationale

Pureeing protein may ease swallowing but does not inherently reduce aspiration risk compared to specific swallowing techniques.

Choice C rationale

Unsupervised snack access increases aspiration risk, as dysphagia requires monitored intake to prevent respiratory complications.

Choice D rationale

Background music may provide relaxation but does not scientifically mitigate aspiration risks in dysphagia-related interventions. .

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Correct Answer is C

Explanation

Choice A rationale

Sleeping on the operative side increases pressure on the eye, risking complications like increased intraocular pressure and disrupted healing of surgical incisions. Postoperative care avoids this positioning.

Choice B rationale

Lifting items over 5-10 pounds risks increased intraocular pressure. Guidelines usually limit lifting to light objects, not 30 pounds. Heavy lifting can cause strain affecting surgical recovery.

Choice C rationale

Eye shields protect the operative site during sleep, preventing accidental trauma, while glasses shield from debris during daytime. These preventive measures support proper healing and recovery post-cataract surgery.

Choice D rationale

Avoiding eye drops disrupts healing as prescribed medications manage inflammation and prevent infections after surgery. Proper use of eye drops supports post-surgical recovery effectively.

A. Can squeeze the nurse's hand upon verbal request. B. Follows simple commands with repetition/prompting from nurse. C. Has purposeful movement when the nurse rubs the sternum. D. Extends upper and lower extremities in response to painful stimuli.

Correct Answer is D

Explanation

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

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A nurse is caring for a client with dysphagia associated with a left-sided stroke and right-sided weakness.Which of the following strategies are appropriate to reduce the risk of aspiration?

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A nurse is caring for a client with dysphagia associated with a left-sided stroke and right-sided weakness.
Which of the following strategies are appropriate to reduce the risk of aspiration?