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: Attaching the restraint to the bed's side rails can increase the risk of injury if the client tries to climb over them. The restraints should instead be attached to be bed frame.
B: Restraints should be removed at least every 2 hours to assess the client's condition and provide necessary care, not every 4 hours.
C: Documentation of the client's condition is essential to ensure proper monitoring and assessment while the restraint is in use.
D: PRN restraint prescriptions should not be used for clients who are aggressive; restraints should only be used as a last resort and with a clear medical justification.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
Conditions:
- Placental abruption, the premature separation of the placenta from the uterine wall, can occur due to hypertension, which increases the risk of vascular damage and bleeding behind the placenta, leading to its separation.
- Oligohydramnios, a condition characterized by a deficiency of amniotic fluid, is typically associated with decreased fetal urine production, renal abnormalities, or placental insufficiency. However, none of the findings listed in the scenario directly correlate with this condition.
- Spontaneous abortion, also known as miscarriage, can occur due to various factors such as genetic abnormalities, hormonal imbalances, or maternal health conditions. However, none of the findings listed in the scenario directly correlate with this condition.
- Chorioamnionitis is an infection of the fetal membranes and amniotic fluid. While maternal fever is often associated with chorioamnionitis, it is not a finding listed in the scenario. Additionally, the other findings do not directly correlate with this condition.
- Placenta previa is a condition where the placenta partially or completely covers the cervix. This condition is not directly associated with the findings listed in the scenario.
Findings:
- Hypertension is a risk factor for placental abruption due to increased vascular resistance, which can lead to vascular damage and placental separation.
- Temperature elevation may indicate an infection, such as chorioamnionitis, which can increase the risk of placental abruption.
- Hyperreflexia can be associated with conditions like preeclampsia, which is characterized by hypertension and can increase the risk of placental abruption.
- Vomiting alone is not directly associated with an increased risk of placental abruption.
- Fundal height measurement can provide information about fetal growth and gestational age but is not directly associated with an increased risk of placental abruption.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.