A client arrives with right-sided weakness and slurred speec… | MyMerci
Changes in Vital SignsROR
Question
A client arrives with right-sided weakness and slurred speech. Which action should the nurse take before offering anything by mouth?
1Ask the client to choose a preferred meal.
2Administer an oral antiplatelet medication immediately.
3Complete or obtain the prescribed swallow screening.✓ Correct answer
4Place the client in a supine position for comfort.
Explanation
A client with possible stroke is at risk for dysphagia and aspiration. Swallow screening should occur before oral intake or oral medications when indicated by protocol. Supine positioning can worsen aspiration risk.
In-depth explanation
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Stroke dysphagia screening.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical scenario
Clinical Practice Guide For Stroke dysphagia screening, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
Caution Do not choose an action from one isolated cue when the full scenario changes priority or safety.
Key concepts
Stroke — An acute neurologic deficit caused by interrupted blood flow or bleeding in the brain.
Dysphagia — Difficulty swallowing that can increase aspiration risk.
Aspiration — Entry of food, fluid, or secretions into the airway.