Difficulty: Medium
Average Score: 63%
Simulated
A nurse is assessing a client who has left-sided weakness following a stroke. Which of the following findings is the nurse's priority?
Correct answer
C
Rationale
The correct answer is C: The client coughs frequently while eating. This is the priority finding because it indicates a risk for aspiration, a potentially life-threatening complication post-stroke. Aspiration occurs when food or liquids enter the airway instead of the esophagus, leading to choking or pneumonia. The nurse should address this immediately by modifying the client's diet consistency or positioning during meals to prevent aspiration.
The other choices are not the priority because:
A: The client's blood pressure being 142/94 mm Hg is elevated but not immediately life-threatening in this context.
B: Consuming only 25% of meals may indicate dysphagia or decreased appetite, which are important but not as urgent as the risk of aspiration.
D: Leaning to the left side while sitting is likely due to the left-sided weakness and can be addressed with positioning adjustments but is not as urgent as preventing aspiration.
The other choices are not the priority because:
A: The client's blood pressure being 142/94 mm Hg is elevated but not immediately life-threatening in this context.
B: Consuming only 25% of meals may indicate dysphagia or decreased appetite, which are important but not as urgent as the risk of aspiration.
D: Leaning to the left side while sitting is likely due to the left-sided weakness and can be addressed with positioning adjustments but is not as urgent as preventing aspiration.