# An immobile adult with dysphagia is on hospital day 4 after acute ischemic stroke. Classify each planned intervention by its primary care goal.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=393415&lang=en  
> language: en  
> subject: Potential for Alterations in Body Systems  
> category: ROR

## Question

An immobile adult with dysphagia is on hospital day 4 after acute ischemic stroke. Classify each planned intervention by its primary care goal.

|  | Aspiration and nutrition | Venous thromboembolism prevention | Mobility and functional recovery |
| --- | --- | --- | --- |
| Complete a validated swallow screen before food, fluids, or oral medications |  |  |  |
| Use short-term enteral feeding when swallowing remains unsafe and oral intake is inadequate |  |  |  |
| Apply intermittent pneumatic compression while the client remains immobile |  |  |  |
| Review bleeding risk and administer prescribed prophylactic-dose anticoagulation when appropriate |  |  |  |
| Begin individualized progressive mobilization when medically stable |  |  |  |
| Protect the affected shoulder and perform prescribed positioning and range-of-motion activities |  |  |  |

## 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.

## In-depth explanation

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

## Clinical scenario

The client is medically stable, has right hemiparesis, and cannot yet swallow safely. The team is preventing aspiration and venous thromboembolism while supporting recovery.

## Key concepts

- **swallow evaluation** — Bedside or instrumental swallow assessment by SLP; precedes oral intake post-stroke.
- **high-intensity statin** — Atorvastatin 40-80 mg or rosuvastatin 20-40 mg; reduces recurrent stroke.
- **secondary prevention** — Interventions reducing recurrent vascular events after stroke.

## Related questions

- [For each clinical scenario, select the corresponding 2022 ACC/AHA/HFSA heart-failure stage…](https://mymerci.kr/pages/nclex_q.php?qn_id=393413&lang=en)
- [An adult is 2 hours post-tenecteplase for acute ischemic stroke. Classify each action for …](https://mymerci.kr/pages/nclex_q.php?qn_id=393414&lang=en)
- [A client admitted with an acute stroke coughs and develops a wet voice during the initial …](https://mymerci.kr/pages/nclex_q.php?qn_id=395564&lang=en)
- [Two hours after a lower-leg fracture is immobilized, the client reports escalating pain de…](https://mymerci.kr/pages/nclex_q.php?qn_id=395612&lang=en)
- [A hospitalized client develops early acute kidney injury after several days of vomiting an…](https://mymerci.kr/pages/nclex_q.php?qn_id=396180&lang=en)
- [Two days after a femur fracture, a client develops sudden hypoxemia, confusion, and a pete…](https://mymerci.kr/pages/nclex_q.php?qn_id=397278&lang=en)
- [A client with a lower-leg fracture in a cast reports rapidly worsening pain despite analge…](https://mymerci.kr/pages/nclex_q.php?qn_id=497750&lang=en)
- [Place the nursing actions in order for an adult client who arrives with an acute onset of …](https://mymerci.kr/pages/nclex_q.php?qn_id=568361&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=393415&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=393415&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=393415&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=393415&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=393415&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._