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 C

Explanation

Understanding the problem:

Original weight: 90.7 kg

Weight lost: 6.8 kg

Calculating the percentage weight loss:

Calculate the ratio of weight lost to original weight:

6.8 kg / 90.7 kg

Convert the ratio to a percentage:

(6.8 kg / 90.7 kg) x 100%

Solving the equation:

(6.8 kg / 90.7 kg) x 100% ≈ 7.5%

A. Tinnitus B. Drooling C. Fever D. Steatorrhea

Correct Answer is C

Explanation

A) Tinnitus: This is not typically associated with pneumonia. Tinnitus refers to ringing in the ears and is more related to auditory issues rather than respiratory infections.

B) Drooling: While drooling may occur in some cases of severe throat infections or in children with difficulty swallowing, it is not a classic sign of pneumonia.

C) Fever: This is the correct answer. Fever is a common manifestation of bacterial pneumonia in children, indicating an immune response to infection. It often accompanies other symptoms like cough and difficulty breathing.

D) Steatorrhea: This refers to fatty stools, which are more associated with malabsorption syndromes or pancreatic issues, not pneumonia. It is not an expected manifestation of bacterial pneumonia.

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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 nurse is discussing weight loss with a client who is concerned about losing 6.8 kg (15 lb) from an original weight of 90.7 kg (200 lb). The nurse should identify the weight loss as which of the following total percentages?

Correct Answer is C

Explanation

A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?

Correct Answer is C

Explanation

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