A client experiences impaired swallowing after a stroke and has ...

[jasdeep_brar]

A client experiences impaired swallowing after a stroke and has worked with speech-language pathology on eating. What nursing assessment best indicates that a priority goal for this problem has been met?
 
  a. Chooses preferred items from the menu
  b. Eats 75 to 100 of all meals and snacks
  c. Has clear lung sounds on auscultation
  d. Gains 2 pounds after 1 week

Question 2

A client had an embolectomy for an arteriovenous malformation (AVM). The client is now reporting a severe headache and has vomited. What action by the nurse takes priority?
 
  a. Administer pain medication.
  b. Assess the client's vital signs.
  c. Notify the Rapid Response Team.
  d. Raise the head of the bed.

[Zebsrer]

Answer to Question 1

ANS: C
Impaired swallowing can lead to aspiration, so the priority goal for this problem is no aspiration. Clear lung sounds is the best indicator that aspiration has not occurred. Choosing menu items is not related to this problem. Eating meals does not indicate the client is not still aspirating. A weight gain indicates improved nutrition but still does not show a lack of aspiration.

Answer to Question 2

ANS: C
This client may be experiencing a rebleed from the AVM. The most important action is to call the Rapid Response Team as this is an emergency. The nurse can assess vital signs while someone else notifies the Team, but getting immediate medical attention is the priority. Administering pain medication may not be warranted if the client must return to surgery. The optimal position for the client with an AVM has not been determined, but calling the Rapid Response Team takes priority over positioning.

[jasdeep_brar]

Thank you

[Zebsrer]

No problemo