A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?

Choice A reason: Sodium level is not a direct measure of fluid volume. While sodium balance can influence fluid status, the serum sodium level can be affected by various factors and does not reliably indicate fluid volume increase on its own.

Choice B reason: Intake and output records are important for managing fluid balance, especially in a hospital setting. However, they can be influenced by many factors, such as incomplete recording or insensible losses, and do not provide a direct measure of fluid retention.

Choice C reason: Daily weight is considered the most reliable measure of fluid retention. Weight changes can reflect fluid balance accurately because 1 liter of fluid is roughly equivalent to 1 kilogram of body weight. In clients with chronic kidney disease, daily weight monitoring can help detect fluid volume increases or decreases promptly. For a client with chronic kidney disease, daily weight monitoring is a key assessment tool for detecting fluid volume changes. It provides a quantifiable and objective measure that can guide interventions to manage fluid balance effectively.

Choice D reason: Tissue turgor, which refers to the skin’s elasticity, is not a reliable measure of fluid volume. It can be influenced by age, edema, and other factors, and changes in turgor may not accurately reflect fluid status in the body.

Choice A reason: Myocardial infarction (MI) is not limited to occurrences with exertion. While stable angina typically occurs during physical activity or emotional stress, MI can happen at any time, even at rest. The underlying cause of an MI is the complete blockage of blood supply to a part of the heart muscle, usually due to a blood clot in a coronary artery. This blockage can lead to the death of heart muscle tissue, a condition that requires immediate medical attention.

Choice B reason: Stable angina does not typically last for more than 30 minutes. It is characterized by chest pain or discomfort that occurs predictably with exertion or emotional stress and is relieved within minutes by rest or nitroglycerin. In contrast, the pain from an MI is more prolonged and severe, and it is not relieved by rest or nitroglycerin. If chest discomfort lasts longer than 15 minutes and is not alleviated by rest or nitroglycerin, it is a warning sign that the individual may be experiencing an MI.

Choice C reason: This is the distinguishing feature between stable angina and an MI. Stable angina is usually relieved within 3-5 minutes by rest or nitroglycerin, which helps to dilate the coronary arteries and improve blood flow to the heart muscle. Nitroglycerin is ineffective in relieving the symptoms of an MI because the problem is not just reduced blood flow but a complete blockage that nitroglycerin cannot overcome.

Choice D reason: The pain associated with an MI typically lasts for more than 15 minutes and can be quite severe. Unlike stable angina, the pain of an MI is not relieved by rest or nitroglycerin. The duration and severity of the pain, along with other symptoms such as shortness of breath, sweating, nausea, or lightheadedness, help differentiate an MI from stable angina.