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NCLEX-RN

Category - Physiological

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A client who was intubated four weeks ago after being hospitalized for a stroke is being assessed for effects of prolonged intubation. What information is most important for the nurse to obtain at this time?

Ability to swallow
Ability to speak
Ability to move the jaw
Ability to eat independently

Explanation

Answer: A - The nurse should evaluate swallowing ability. Swallowing difficulties increase the risk of aspiration. The remaining information is important but not as urgent as preventing aspiration. Other long-term effects of intubation are inability to speak from lack of use of laryngeal muscles, along with inability to move the jaw and eat independently.

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