A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain?

Changes in appetite

Prescribed medications

Daily fluid intake

wallowing ability

Answer and Explanation

The Correct Answer is D

A) Changes in appetite: While changes in appetite are important to assess, they are not the most immediate concern for a client with ALS who is experiencing weight loss. Appetite changes can contribute to weight loss, but other factors may be more critical.

B) Prescribed medications: Knowing the client’s prescribed medications is essential for overall care, but it is not the priority when addressing recent weight loss in a client with ALS. Medications can affect appetite and weight, but immediate physical concerns should be prioritized.

C) Daily fluid intake: Assessing daily fluid intake is important for hydration status, but it is not the priority in this scenario. Ensuring adequate fluid intake is necessary, but it does not directly address the potential complications related to weight loss in ALS.

D) Swallowing ability: Swallowing ability is the priority admission data to obtain for a client with ALS who has had recent weight loss. ALS can affect the muscles involved in swallowing, leading to dysphagia (difficulty swallowing). This can result in inadequate nutrition and hydration, as well as an increased risk of aspiration. Assessing swallowing ability helps identify the need for interventions such as dietary modifications, swallowing therapy, or alternative feeding methods to ensure the client’s safety and nutritional needs are met.

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Correct Answer is A

Explanation

A. Faint pedal pulse of left leg: A faint pedal pulse indicates poor circulation and is a clear sign of altered tissue perfusion. It suggests that the blood flow to the affected extremity may be compromised, warranting immediate assessment and intervention.

B. Pain with movement of the left great toe: While pain may indicate an issue, it does not specifically indicate altered tissue perfusion. Pain can result from various causes, including injury or inflammation, but it is not a direct measure of blood flow.

C. Purulent drainage at the pin site: Purulent drainage suggests infection rather than altered perfusion. While infections can affect tissue health, this finding does not directly indicate compromised blood flow to the extremity.

D. Warm skin temperature distal to pin site: Warm skin typically suggests adequate perfusion, as warmth can indicate good blood flow. In contrast, coolness or coldness would be a more concerning sign of altered perfusion.

A. "I should expect the provider to evaluate the client within 4 hours of restraint application." B. "I should visually monitor the clit continuously when in mechanical restraints." C. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." D. "I should ask the provider to write a prescription for mechanical restraints as needed."

Correct Answer is B

Explanation

A) “I should expect the provider to evaluate the client within 4 hours of restraint application.”:The provider must evaluate the client within a shorter timeframe, typically within 1 hour of applying mechanical restraints, to ensure the client’s safety and appropriateness of the intervention.

B) “I should visually monitor the client continuously when in mechanical restraints.”:Continuous visual monitoring is essential to ensure the client’s safety and well-being while in mechanical restraints. This allows for immediate intervention if any complications or distress arise.

C) “I should assess the client’s skin integrity every 8 hours while in mechanical restraints.”:Skin integrity should be assessed more frequently, typically every 2 hours, to prevent skin breakdown and other complications associated with prolonged use of restraints.

D) “I should ask the provider to write a prescription for mechanical restraints as needed.”:Mechanical restraints should not be used on an as-needed basis. They require a specific, time-limited order from a provider, and their use must be justified and documented according to strict guidelines and protocols.

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A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain?

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