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. "Information Technology will install a firewall to secure client information.": This statement is appropriate as it highlights the importance of cybersecurity measures, such as firewalls, in protecting client information within a computerized documentation system.

B. "Documentation of sensitive material is performed by the charge nurse.": This statement is misleading. While charge nurses may have responsibilities for certain documentation, all licensed nurses are responsible for accurately documenting sensitive materials related to their own patient care.

C. "You will be given access to the medical records of every client in the facility.": This is incorrect. Access to client medical records should be based on the nurse's role and the specific clients they are caring for, adhering to confidentiality and privacy policies.

D. "You will be asked to change your password once per year.": This is not sufficient for maintaining security. Best practices typically recommend changing passwords more frequently (e.g., every 3-6 months) to enhance security and protect sensitive information.

A. Flumazenil B. Protamine C. Acetylcysteine D. Naloxone

Correct Answer is D

Explanation

A) Flumazenil: Flumazenil is a benzodiazepine antagonist used to reverse the effects of benzodiazepine overdose. Since the client received hydromorphone, which is an opioid, flumazenil would not be the appropriate medication to administer in this situation. The respiratory depression is likely due to opioid use, so this option does not address the client’s specific needs.

B) Protamine: Protamine is a medication used to reverse the effects of heparin, an anticoagulant. It is not indicated for opioid overdose or respiratory depression caused by opioids. Therefore, administering protamine would not be relevant in this scenario and would not help address the client's low respiratory rate.

C) Acetylcysteine: Acetylcysteine is primarily used as an antidote for acetaminophen overdose and to help loosen mucus in conditions like cystic fibrosis. It does not have a role in reversing opioid effects. The client’s respiratory depression following hydromorphone administration would not be treated with acetylcysteine.

D) Naloxone: Naloxone is an opioid antagonist specifically designed to reverse the effects of opioid medications, including respiratory depression. Given that the client is experiencing a significantly low respiratory rate of 10/min after receiving hydromorphone, naloxone is the most appropriate medication to administer promptly to restore normal respiratory function.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is teaching a newly licensed nurse about the facility's computerized documentation system. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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