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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While hospice care may be appropriate for the client, it does not directly address the client's reported depression.
B. Discussing advance directives is important for end-of-life care planning, but it may not address the client's current emotional needs.
C. Offering spiritual support acknowledges the client's emotional distress and provides an opportunity for comfort and guidance that aligns with the client's values and beliefs.
D. Offering medication without further assessment or exploration of the client's feelings may not be the most therapeutic response to the reported depression.

A. "Repeat the dose if your child vomits within 1 hour after taking the medication." B. "You can add the medication to a half-cup of your child's favorite juice" C. "Limit your child's potassium intake while she is taking this medication. D. "Have your child drink a small glass of water after swallowing the medication.

Correct Answer is D

Explanation

A. It's important not to repeat a dose of digoxin if vomited soon after administration due to the risk of toxicity. Instead, parents should contact their healthcare provider for guidance.
B. Mixing digoxin with a large volume of liquid can lead to inaccurate dosing if the child does not consume all the liquid.

C. Digoxin affects potassium levels in the heart muscle; thus, maintaining a normal dietary intake of potassium is important, not limiting it, as hypokalemia can increase the risk of digoxin toxicity.
D. Having water after taking digoxin helps ensure that the medication is swallowed completely and minimizes the risk of esophageal irritation. It aids in proper absorption of the drug.

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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

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