An immobile adult with dysphagia is on hospital day 4 after acute ischemic stroke. Classify each planned intervention by its primary care goal.
Matrix
Choose your responses, then check the answer.
Explanation
Swallow screening and temporary enteral nutrition planning address aspiration and nutrition. Intermittent pneumatic compression and individualized pharmacologic prophylaxis after bleeding-risk review address venous thromboembolism. Progressive mobilization when stable and protected positioning or range-of-motion work address mobility and functional recovery. The categories identify the primary purpose; all six actions are appropriate when individualized to the client.
Correct Answer Rows 1 and 2 address aspiration and nutrition, rows 3 and 4 address VTE prevention, and rows 5 and 6 address mobility and functional recovery.
Why It Fits The client has simultaneous risks, so the nurse links each action to the problem it is designed to prevent or improve.
Clinical Picture Dysphagia threatens airway safety and nutrition; immobility raises thrombosis risk; hemiparesis requires safe, progressive rehabilitation and limb protection.
Memory Link Swallow and feed; compress and prophylax; position and progress.
NCLEX Rule Choose individualized, evidence-based actions and do not substitute prolonged bedrest, routine early PEG placement, or elastic stockings alone for the indicated plan.
Why the Alternatives Fail A goal mismatch can hide an omitted risk. For example, pneumatic compression does not correct dysphagia, and a swallow screen does not prevent immobility-related thrombosis.
Sources
12026 AHA/ASA Acute Ischemic Stroke Guideline
22026 NCLEX-RN Test Plan
The client is medically stable, has right hemiparesis, and cannot yet swallow safely. The team is preventing aspiration and venous thromboembolism while supporting recovery.
swallow evaluation — Bedside or instrumental swallow assessment by SLP; precedes oral intake post-stroke.