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.
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Related Questions
Correct Answer is C
Explanation
A: Directing anyone who becomes angry to leave the room may escalate tensions and hinder resolution.
B: Establishing demands from each party can create a confrontational atmosphere where parties are more focused on winning than resolving the conflict.
C: In resolving staff conflicts, facilitating discussion until all parties agree is a constructive strategy that promotes understanding and collaboration. This approach encourages open communication, allows for the expression of different viewpoints, and works towards a consensus that respects everyone's needs and concerns.
D: Determining fault can increase defensiveness and hinder collaboration in resolving the conflict. It is counterproductive as it places blame, which can lead to defensiveness and hinder the resolution process.
Correct Answer is D
Explanation
A. Changing a dressing on an implanted central venous access device involves a sterile procedure and assessment, requiring the skills and knowledge of a licensed nurse.
B. Removing an NG tube is a task beyond an AP’s scope and requires the specialized skills of a registered nurse.
C. Suctioning a tracheostomy requires specialised training and skill to perform safely and should not be delegated to assistive personnel.
D. Performing postmortem is within the scope of an assistive personnel. It does not require any specialized skills and knowledge of a registered nurse.
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