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 D

Explanation

Choice A rationale

Approaching the client from the unaffected side does not stimulate compensation or adaptation. It limits the opportunity for neural adjustment and rehabilitation to optimize functional use of the affected side.

Choice B rationale

Eye patches may address double vision but are ineffective in enhancing sensory perception compensation for hemianopsia. Rehabilitation focuses on improving spatial awareness, not restricting visual fields.

Choice C rationale

Muscle exercises aid ocular health but do not scientifically compensate for hemianopsia. Scanning techniques provide more effective sensory perception rehabilitation in spatial deficits caused by this condition.

Choice D rationale

Scanning techniques teach clients to move their head or eyes consciously to view their entire surroundings. This method compensates for sensory deficits, helping clients adapt effectively during rehabilitation. .

A. Prevent the drainage by applying a pressure dressing. B. Allow fluid to drain from the patient's ear onto gauze and notify the provider. C. Hang intravenous (IV) fluids to replace fluids lost. D. Administer antibiotics due to increased risk of infection.

Correct Answer is B

Explanation

Choice A rationale

Applying pressure to prevent drainage could force cerebrospinal fluid (CSF) back into the cranial cavity, increasing infection risk and intracranial pressure, potentially worsening brain injury. CSF leakage requires non-obstructive handling.

Choice B rationale

Allowing fluid to drain onto gauze prevents build-up of intracranial pressure while assessing for halo sign, indicating CSF leakage. Yellow staining reflects glucose presence in CSF, confirming dura mater damage.

Choice C rationale

Intravenous fluids manage hypovolemia but are not prioritized for trauma patient brain injuries. Replacing lost CSF requires specific medical intervention rather than fluid volume adjustments alone.

Choice D rationale

Antibiotics treat infections but are not first priority for confirmed CSF leakage, which demands careful monitoring of drainage to prevent neurological damage. Post-intervention antibiotics may be necessary.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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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?