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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The latent period of HIV includes asymptomatic phases when the CD4+ count remains above 200 cells/mm. Pneumocystic pneumonia and low CD4+ counts signify progression beyond latent HIV.
Choice B rationale
HIV-positive status reflects infection presence, but it does not confirm AIDS unless CD4+ count drops below 200 cells/mm and opportunistic infections occur, such as pneumocystic pneumonia.
Choice C rationale
AIDS is diagnosed when CD4+ count decreases below 200 cells/mm, coupled with opportunistic infections. Pneumocystic pneumonia indicates a weakened immune system due to advanced disease.
Choice D rationale
Seroconversion marks the initial immune response to HIV infection with detectable antibodies but occurs before CD4+ counts decline significantly and opportunistic infections appear.
Correct Answer is A
Explanation
Choice A rationale
Cerebellar injury affects balance and coordination; ensuring bed alarm use prioritizes safety for patients who are at high fall risk due to impaired motor control and unsteady gait.
Choice B rationale
Reorientation addresses confusion, often linked to cognitive or frontal brain injuries, not cerebellar function, which mainly regulates coordination and balance rather than higher-order thinking.
Choice C rationale
Turning every 2 hours prevents skin breakdown but is more relevant to immobilized patients, not those with cerebellar injuries where mobility and fall prevention are the primary concerns.
Choice D rationale
Varying the schedule may stimulate engagement but does not directly address fall risks or coordination issues, which are critical for patients with cerebellar injuries.
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