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7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
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1. Hoarseness, 3. Coughing, 4. Drooling, and 5. Gurgling
Hoarseness may be a sign of laryngeal inflammation as a result of microaspiration and should be clustered with the group of signs presented in the question.
The body continuously secretes saliva (approx. 1,000 mL/day) that usually is swallowed. If a client is having difficulty swallowing, the client may aspirate saliva, which can cause coughing. Coughing in addition to the client's other clinical manifestations indicates that the client may have impaired swallowing.
The body continuously secretes saliva (approx. 1,000 mL/day) that usually is swallowed. When saliva accumulates nd is not swallowed, it dribbles out of the mouth (drooling). Drooling in addition to the client's other clinical manifestations indicates that the client may have impaired swallowing.
The body continuously secretes saliva (approx. 1,000 mL/day) that usually is swallowed. When saliva accumulates and is not swallowed, it makes a bubbling or gargling sound in the posterior oropharynx as air is inhaled and exhaled.
4. "What brought you to the hospital today?"
Objective and subjective data must be collected, verified, and communicated during the assessment step of the nursing process.
2. "The client's clinical manifestation indicate dehydration."
Data are clustered and analyzed, and their significance is determined,
leading to a conclusion about the client's condition, during the analysis step of the nursing process.
3. "The client will have a bowel movement in the morning"
Identifying goals, projecting outcomes setting priorities, and identifying interventions are all part of the planning step of the nursing process.
5. "I am going to give you an enema."
Planned actions are initiated and completed during the implementation step of the nursing process.
1. "Did you sleep last
night after I gave you the sleeping medication"
Identifying responses to care, comparing actual outcomes, analyzing factors that affected outcomes, and modifying the plan of care if necessary are all part of the evaluation step of the nursing process.
Pharmacology and the Nursing Process
7th EditionJulie S Snyder, Linda Lilley, Shelly Collins
388 solutions
Clinical Reasoning Cases in Nursing
7th EditionJulie S Snyder, Mariann M Harding
2,512 solutions
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3rd EditionDouglas Singh, Leiyu Shi
188 solutions