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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: This is not accurate since the manifestations of facial nerve paralysis are observed on the contralateral side which in this case is the left side of the face hence the right facial nerve is paralyzed.
Choice B rationale: Facial nerve paralysis cause symptoms such as drooping of the eyelid, cheek or mouth as depicted in the above picture. The right facial nerve is paralyzed since the nerve innervates the contralateral side hence the effects are demonstrated on the
left side of the face.
Choice C rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.
Choice D rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.
Correct Answer is B
Explanation
Choice A rationale: This is a positive Trousseau's sign, which indicates hypocalcemia or tetany. It is not related to meningitis or meningeal irritation.
Choice B rationale: Kernig's sign is indicated when there is resistance and pain with knee extension and hip flexion, suggesting meningeal irritation.
Choice C rationale: This is a positive Homan's sign, which indicates deep vein thrombosis or phlebitis. It is not related to meningitis or meningeal irritation.
Choice D rationale: This is a sign of nuchal rigidity, which indicates meningeal irritation, but it is not specific to Kernig's sign. Nuchal rigidity can also be caused by other conditions such as cervical arthritis or muscle spasm.
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