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 C
Explanation
A. Metoprolol is a beta-blocker used to treat hypertension and other cardiovascular conditions.
While it may be important for the provider to be aware of all medications, it is not the priority to report in this scenario.
B. Clopidogrel is an antiplatelet medication used to prevent blood clots in individuals at risk for cardiovascular events. While it may have implications for the procedure, it is not the priority to report in this scenario.
C. Metformin is an oral antidiabetic medication commonly used to treat type 2 diabetes. It is
important to report because there may be specific considerations regarding its use in the context of a colonoscopy, such as the risk of lactic acidosis.
D. Digoxin is a medication used to treat heart failure and certain arrhythmias. While it may have implications for the procedure, it is not the priority to report in this scenario.
Correct Answer is A
Explanation
A.
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.
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