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?
Swallowing ability
Changes in appetite
Prescribed medications
Daily fluid intake
The Correct Answer is A
A: Swallowing ability is crucial because ALS often leads to dysphagia, which can cause weight loss due to difficulty eating and the risk of aspiration.
B: Changes in appetite are important but secondary to physical ability to eat safely.
C: While knowing about prescribed medications is necessary, it does not directly address the issue of weight loss as critically as swallowing ability.
D: Fluid intake is important but the priority is assessing the ability to swallow safely, which directly impacts nutritional status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Chorioamnionitis, an infection of the fetal membranes, can lead to fetal tachycardia and no bradycardia
B. Fetal anemia might present with tachycardia rather than bradycardia.
C. Maternal hypoglycemia can cause fetal bradycardia since when a mother experiences hypoglycemia, it can result in inadequate blood glucose levels that are crucial for both her and the fetus. This condition can impair the oxygen and nutrient delivery to the fetus, as the mother's body prioritizes her own metabolic needs. Consequently, the fetal heart rate may slow down as a response to the stress of reduced energy supply.
D. Maternal fever is associated with fetal tachycardia rather than bradycardia.
Correct Answer is B
Explanation
A. Flattening of the artificial airway cuff. This would indicate a problem, such as a leak, not a successful outcome of suctioning.
B. This indicates that the airway resistance has been reduced following suctioning, which suggests that the suctioning was effective in clearing the airway obstruction caused by secretions.
C. Thinning of mucous secretions is not a direct indication of effective suctioning; while thinner secretions may be easier to remove, the goal of suctioning is to clear the airways rather than alter the consistency of the secretions.
D. The presence of a productive cough is not relevant in the context of a patient who is intubated and mechanically ventilated, as they would be unable to cough effectively due to the endotracheal tube.
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