Difficulty: Medium
Average Score: 90%
Simulated
A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurseÔÇÖs priority?
Correct answer
B
Rationale
The correct answer is B: The client coughs frequently while eating. This is the priority because it indicates a risk of aspiration, which can lead to serious complications like pneumonia. Aspiration occurs when food or liquid enters the airway instead of the esophagus. The nurse should address this immediately to prevent respiratory issues.
A: Leaning to the left side is concerning but does not pose an immediate threat to the client's health compared to aspiration risk.
C: Consuming only 25% of meals is important but does not pose an immediate risk to the client's health as aspiration does.
D: While high blood pressure is a concern, it is not the priority over the risk of aspiration. The nurse should address the immediate threat first.
A: Leaning to the left side is concerning but does not pose an immediate threat to the client's health compared to aspiration risk.
C: Consuming only 25% of meals is important but does not pose an immediate risk to the client's health as aspiration does.
D: While high blood pressure is a concern, it is not the priority over the risk of aspiration. The nurse should address the immediate threat first.