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 A
Explanation
Choice A rationale
Metoprolol decreases cardiac workload by reducing heart rate and myocardial oxygen demand. A heart rate of 62 is within normal limits, demonstrating effective beta-blocker action and improved cardiac efficiency.
Choice B rationale
Lying flat without difficulty breathing reflects improved respiratory status, which is more related to pulmonary management, not directly indicative of reduced cardiac workload or beta-blocker efficacy.
Choice C rationale
Absence of dyspnea after climbing stairs suggests improved physical fitness but does not directly measure the cardiac effects of metoprolol, which targets heart rate reduction and myocardial oxygen use.
Choice D rationale
Weight loss is related to overall health improvement or dietary changes rather than specific effects of metoprolol, which primarily impacts heart rate and cardiac oxygen consumption.
Correct Answer is B
Explanation
Choice A rationale
Basilar skull fractures can lead to cerebral injuries and CSF leaks, but do not typically cause anoxic brain injury unless they compromise oxygenation or cause cerebral edema severely reducing blood flow.
Choice B rationale
Prolonged submersion compromises oxygen delivery, leading to diffuse cerebral hypoxia or anoxia, the primary cause of brain injury in drowning victims due to interruption of arterial oxygenation over unknown durations.
Choice C rationale
Epidural or subdural hematomas elevate intracranial pressure and compress brain tissue, but they are not as immediately hypoxic as situations involving complete oxygen deprivation like submersion.
Choice D rationale
Prolonged seizures, or status epilepticus, may disrupt normal metabolic processes, potentially causing neuronal injury. However, primary hypoxia is generally less pronounced than in submersion cases.
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