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 A

Explanation

Choice A Reason:

Constant bubbling in the water seal chamber of a chest drainage system typically indicates an air leak. This can occur if there is a break in the system, allowing air to enter. The air leak could be from the chest tube insertion site, the tubing, or the drainage system itself. Identifying and correcting the source of the air leak is crucial to ensure the system functions properly and the patient’s condition does not worsen.

Choice B Reason:

A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, leading to increased pressure on the lungs and other thoracic structures. While a tension pneumothorax can cause significant respiratory distress, it is not typically indicated by constant bubbling in the water seal chamber. Instead, signs of tension pneumothorax include tracheal deviation, hypotension, and severe respiratory distress.

Choice C Reason:

A kink in the tubing of a chest drainage system can obstruct the flow of air and fluid, but it does not cause constant bubbling in the water seal chamber. Instead, a kink would likely result in a lack of drainage or intermittent bubbling as the obstruction temporarily blocks and then allows passage of air or fluid.

Choice D Reason:

Increased drainage in a chest tube system indicates that more fluid or air is being removed from the pleural space, but it does not cause constant bubbling in the water seal chamber. Increased drainage might be seen in cases of hemothorax or pleural effusion, where large amounts of fluid are present.

Choice E Reason:

Tidaling refers to the normal rise and fall of water in the water seal chamber with the patient’s respiratory cycle. It indicates that the chest tube is patent and functioning correctly. Absence of tidaling could suggest that the lung has fully re-expanded or that there is an obstruction in the system. However, tidaling itself does not cause constant bubbling.

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

The nurse is taking care of a 60-year-old client with constant bubbling in the water seal chamber. The nurse knows that constant bubbling in the water seal of a chest drainage system indicates which problem?

Correct Answer is A

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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