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    ATI NUR 112 Fundamentals Proctored Exam III
    Select All That Apply

    A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke.Which of the following actions should the nurse take?

    Explanation & Rationale

    Choice A rationaleAdding thickener to fluids helps to increase their viscosity, making them easier to swallow and reducing the risk of aspiration in clients with dysphagia. Dysphagia often results from impaired muscle control in the mouth and throat, and thicker fluids move more slowly, allowing more time for coordination of the swallowing reflex.Choice B rationalePlacing food on the right side of the client's mouth addresses the left-sided weakness following a stroke. This allows the client to use the stronger, unaffected side of their mouth and throat for better control during chewing and swallowing, minimizing the risk of food pooling on the weaker side and potential aspiration.Choice C rationaleServing food at a very hot temperature can impair the client's ability to sense the food in their mouth and can increase the risk of burns, especially with sensory deficits that can occur after a stroke. Warm or room temperature foods are generally recommended for clients with dysphagia to enhance safety and comfort.Choice D rationaleInstructing the client to tilt her head forward when swallowing helps to close the airway and open the esophagus, facilitating the passage of food and liquids down the throat and reducing the risk of aspiration into the trachea and lungs. This chin-tuck maneuver is a common compensatory strategy for dysphagia. .

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