A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. The client's primary diagnosis is amyotrophic lateral sclerosis (ALS). The client can transfer from the bed to a chair but can't walk.

The client and their family are concerned about the client's ability to maintain mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is ...

Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate.

Hopelessness related to impaired ability to cope.

Caregiver role strain related to care recipient's unrealistic expectations of caregiver.

Impaired memory related to reduced quality and quantity of information processed.

Answer and Explanation

The Correct Answer is A

Choice A rationale: In ALS, impaired physical mobility due to decreased motor agility and the inability to ambulate is a direct consequence of the disease.

Choice B rationale: Hopelessness might be a possible emotional response but doesn't address the client's physical limitations due to ALS.

Choice C rationale: Caregiver role strain is related to the family's ability to manage caregiving responsibilities and is not the primary concern for the client's physical mobility.

Choice D rationale: Impaired memory is not the primary issue in ALS; the client's inability to ambulate due to decreased motor function is the main focus for this nursing diagnosis.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.

Choice B rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.

Choice C rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.

Choice D rationale: Serosanguineous nasal drainage (a mixture of blood and clear fluid) may suggest a basilar skull fracture, which is a fracture of the base of the skull that can damage vital structures such as the brainstem, cranial nerves, or major blood vessels. This can lead to serious complications such as meningitis, cerebrospinal fluid leak, or hemorrhage.

A. Stools constantly oozing from the rectum B. Chronic constipation C. Diarrhea D. Constipation alternating with diarrhea

Correct Answer is C

Explanation

Choice A rationale: Not a typical characteristic of Crohn's disease; more associated with conditions like rectal fistulas.

Choice B rationale: Crohn's disease commonly involves diarrhea rather than chronic constipation.

Choice C rationale: A common symptom of Crohn's disease due to inflammation and malabsorption in the intestines.

Choice D rationale: Crohn's disease typically presents with diarrhea but not necessarily alternating with constipation. Constipation alternating with diarrhea may also occur in irritable bowel syndrome.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?

Correct Answer is D

Explanation

The nurse is reviewing the record of a female client with Crohn's disease. Which stool characteristics should the nurse expect to note documented in the client's record?

Correct Answer is C

Explanation

When providing care for a client receiving peritoneal dialysis. While draining the dialysate the nurse notices that the efluent is cloudy. Which intervention is most important for the nurse to carry out at this moment?

A patient who has numbness and weakness of both feet is hospitalized with Guillain- Barré syndrome. The nurse will anticipate that collaborative interventions at this time will include ...

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer?

The nurse reviews the laboratory reports of a client and concludes that the client has diabetes. Which finding helped the nurse to reach this conclusion?

A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first?

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note?

While assessing a male client, a nurse observes that the client has a small penis, long legs, short trunk, enlarged breast tissues, small testicles, and sexual dysfunction. What diagnosis does the nurse suspect from these findings?

The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the nurse analyze for evidence of hypoxemia and metabolic acidosis in a client with shock?