A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met?

Gains 2 lbs (1 kg) after 1 week.

Chooses preferred items from the menu.

Clearly understands and articulates.

Eats 75 to 100% of all meals and snacks.

Answer and Explanation

The Correct Answer is J

Choice A Reason:

Gaining weight can be an indicator of improved nutrition, but it does not directly address the client’s ability to swallow safely and effectively. Weight gain could be due to other factors such as fluid retention or changes in metabolism. Therefore, while it is a positive outcome, it is not the best indicator of improved swallowing function.

Choice B Reason:

Choosing preferred items from the menu indicates that the client is engaged in their meal planning and has an appetite. However, it does not directly measure the client’s ability to swallow safely. The client might still have difficulty swallowing even if they are choosing their preferred foods.

Choice C Reason:

Clear understanding and articulation are important for communication and can indicate cognitive improvement. However, this choice does not directly relate to the client’s swallowing ability. The primary concern in this scenario is the client’s ability to swallow safely, not their communication skills.

Choice D Reason:

Eating 75 to 100% of all meals and snacks is the best indicator that the client has improved their swallowing ability. This choice directly measures the client’s ability to consume food and liquids safely and effectively. It shows that the client can manage their meals without significant difficulty, which is the primary goal of the intervention.

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Correct Answer is C

Explanation

Choice A Reason:

Nonfat milk is generally considered safe for individuals with GERD. While full-fat dairy products can exacerbate GERD symptoms due to their high-fat content, nonfat milk does not have this effect. It is low in fat and unlikely to trigger acid reflux. Therefore, nonfat milk is not a food that needs to be avoided by someone with GERD.

Choice B Reason:

Apples are typically safe for individuals with GERD. In fact, non-citrus fruits like apples are often recommended as part of a GERD-friendly diet. They are low in acid and unlikely to cause reflux symptoms. Therefore, apples do not need to be avoided by someone with GERD.

Choice C Reason:

Chocolate is a common trigger for GERD symptoms. It contains caffeine and theobromine, both of which can relax the lower esophageal sphincter (LES), allowing stomach acid to escape into the esophagus and cause reflux. Additionally, chocolate is high in fat, which can further exacerbate GERD symptoms. Therefore, it is advisable for individuals with GERD to avoid chocolate to prevent worsening of their symptoms.

A. Increased temperature B. Increased respiratory rate C. Increased hematocrit D. Increased heart rate E. Increased blood pressure

Correct Answer is ["A","B","C"]

Explanation

Choice A: Increased Respiratory Rate

Fluid overload, also known as hypervolemia, can lead to an increased respiratory rate. This occurs because the excess fluid in the body can accumulate in the lungs, leading to pulmonary congestion and edema. As a result, the body attempts to compensate by increasing the respiratory rate to improve oxygenation and remove excess carbon dioxide. Normal respiratory rate for adults is typically between 12-20 breaths per minute. An increased respiratory rate above this range can indicate fluid overload.

Choice B: Increased Heart Rate

An increased heart rate, or tachycardia, is another common finding in clients with fluid overload. The heart has to work harder to pump the excess fluid throughout the body, leading to an increased heart rate. This is a compensatory mechanism to maintain adequate cardiac output and tissue perfusion. Normal resting heart rate for adults is between 60-100 beats per minute. A heart rate above this range can be indicative of fluid overload.

Choice C: Increased Blood Pressure

Fluid overload can also result in increased blood pressure, or hypertension. The excess fluid in the bloodstream increases the volume of blood that the heart has to pump, leading to higher pressure within the arteries. This can strain the cardiovascular system and lead to complications if not managed properly. Normal blood pressure is typically around 120/80 mmHg. Blood pressure readings consistently above this range can suggest fluid overload.

Choice D: Increased Hematocrit

Increased hematocrit is not typically associated with fluid overload. Hematocrit is the proportion of red blood cells in the blood. In cases of fluid overload, the hematocrit level is usually decreased due to the dilutional effect of the excess fluid. Therefore, this choice is incorrect.

Choice E: Increased Temperature

Increased temperature is not a common finding in fluid overload. Fever or elevated body temperature is more commonly associated with infections or inflammatory conditions. Fluid overload does not typically cause an increase in body temperature. Therefore, this choice is incorrect.

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A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that the expected outcome for this problem has been met?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid?

Correct Answer is C

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

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