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 D

Explanation

A) Rotate health care staff caring for the client: While having a variety of staff can provide different perspectives, it may not be the best approach for immunosuppressed clients. Consistency in care is often more beneficial, as it helps to minimize exposure to different pathogens.

B) Monitor the client's vital signs every 12 hr: Monitoring vital signs is important, but for clients with immunosuppression, more frequent monitoring is often necessary. This can help detect early signs of infection or complications that may arise more rapidly in this population.

C) Provide fresh fruit with the client's meals: Fresh fruits can pose a risk of bacterial contamination, particularly for immunosuppressed clients. It is generally safer to provide cooked fruits or fruit that has been properly washed and peeled to minimize this risk.

D) Inspect the client's mouth every 8 hr: Regular oral assessments are crucial for clients experiencing immunosuppression, as they are at a higher risk for oral infections and mucositis. This intervention allows for early detection and management of any abnormalities, thus promoting better overall health.

A. Administer 1 L dextrose 5% in water IV bolus prior to the procedure. B. Initiate NPO status 4 hr prior to the procedure. C. Position the client over an overbed table prior to the procedure. D. Instruct the client to empty her bladder prior to the procedure.

Correct Answer is D

Explanation

A) Administer 1 L dextrose 5% in water IV bolus prior to the procedure: Administering a large volume IV bolus is generally unnecessary before a paracentesis. It can lead to abdominal distension and discomfort, potentially complicating the procedure. Fluid management should be carefully considered based on the client’s condition rather than a standard bolus.

B) Initiate NPO status 4 hr prior to the procedure: Paracentesis typically does not require NPO status unless sedation is planned, which is uncommon. Keeping the client NPO can cause unnecessary discomfort and does not align with standard pre-procedural care for a paracentesis, which usually allows for regular oral intake.

C) Position the client over an overbed table prior to the procedure: While positioning is crucial for comfort and access, clients are generally positioned sitting at the edge of the bed or in a semi-Fowler's position. An overbed table may not provide adequate support and could lead to discomfort or complications during the procedure.

D) Instruct the client to empty her bladder prior to the procedure: This action is important as it helps reduce the risk of bladder injury during the paracentesis and minimizes discomfort. An empty bladder allows for better access to the abdominal cavity, indicating that the nurse understands the necessary preparations for the procedure.

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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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