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

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

A. The patient will recall events from childhood. B. The patient will return to work as a corporate attorney. C. The patient will actively participate in the rehabilitation process as appropriate. D. The patient will demonstrate improved motor coordination within two weeks.

Correct Answer is C

Explanation

Choice A rationale

Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.

Choice B rationale

Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.

Choice C rationale

Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.

Choice D rationale

Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.

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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?