A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to reduce the risk of aspiration?

Have the client point their chin upward to swallow.

Offer the client saltine crackers between meals.

Thicken liquids before serving.

Place food on the affected side of the mouth.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Having the client point their chin upward to swallow is not a recommended action to reduce the risk of aspiration. In fact, this action can increase the risk of choking and aspiration, as it may cause food or liquids to enter the airway.
Choice B rationale:
Offering the client saltine crackers between meals is not a suitable action for reducing the risk of aspiration. Saltine crackers are dry and can be challenging to swallow for someone with dysphagia, potentially increasing the risk of aspiration.
Choice C rationale:
Thicken liquids before serving is the correct action to reduce the risk of aspiration in a client with dysphagia. Thickened liquids are easier to swallow and less likely to enter the airway, reducing the risk of aspiration pneumonia.
Choice D rationale:
Placing food on the affected side of the mouth does not address the risk of aspiration directly. Dysphagia may affect both sides of the mouth, and placing food on one side does not ensure safe swallowing and reduces the effectiveness of addressing the problem.

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Correct Answer is C

Explanation

Choice A rationale:

Difficulty maintaining personal hygiene is not typically an early indication of mild Alzheimer's disease. In the early stages, individuals can still manage personal hygiene.

Choice B rationale:

Difficulty handling finances may occur in the later stages of Alzheimer's disease, but it is not an early indication. In the early stages, the person might still manage financial matters.

Choice C rationale:

Difficulty remembering the names of new friends is a common early sign of mild Alzheimer's disease. It reflects the impairment of short-term memory that often occurs in the early stages of the disease.

Choice D rationale:

Difficulty driving to and from familiar places is more likely to be a mid-to-late-stage symptom of Alzheimer's disease. In the early stages, individuals might still drive familiar routes with minimal difficulty.

A. Place the client in a low Fowler's position with the knees bent. B. Cover the client's wound with a sterile saline-soaked dressing. C. Notify the surgeon about the finding. D. Prepare the client for transfer to surgery.

Correct Answer is D

Explanation

Choice A rationale:
Placing the client in a low Fowler's position with the knees bent (Choice A) can help reduce tension on the abdominal incision, but it is not the priority when evisceration is present. The focus should be on immediate intervention and preparation for surgery.
Choice B rationale:
Covering the client's wound with a sterile saline-soaked dressing (Choice B) is essential to prevent further contamination and maintain moisture in the exposed tissue. This step helps protect the wound until the client can be taken to the operating room.
Choice C rationale:
Notifying the surgeon about the finding (Choice C) is important, but it should not be done before taking more immediate action. Evisceration requires prompt intervention and transfer to surgery, and the surgeon will be involved once the client is ready for the operation.
Choice D rationale:
Preparing the client for transfer to surgery (Choice D) is the correct sequence of steps in this situation. Evisceration is a surgical emergency that requires immediate intervention to prevent complications and infection. The nurse should stabilize the wound with a sterile dressing and then prepare the client for surgery promptly.

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A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to reduce the risk of aspiration?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client for manifestations of mild Alzheimer's disease. Which of the following findings should the nurse expect as an early indication of the disease?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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