A nurse is providing teaching to a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following client statements indicates an understanding of the teaching?
"I need to make sure other members of my family get immunized against the disease."
"Since I will stay in the hospital, I should begin the process of selling my home."
"I will need to begin hospice care immediately."
"I would like to talk to someone about creating a living will."
The Correct Answer is D
Choice A rationale:
Other family members or close contacts may consider immunization, but it is not directly related to the client's ALS diagnosis.
Choice B rationale:
Since the client has a new diagnosis of ALS, the immediate focus should not be on selling their home, but rather on understanding and managing the disease.
Choice C rationale:
Requiring hospice care immediately is not a standard recommendation for a client with ALS. The client's disease progression and needs will be assessed to determine the appropriate level of care.
Choice D rationale:
Creating a living will is important for clients with a terminal illness like ALS, as it allows them to express their wishes for medical treatment and care preferences in advance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Assessing for the client's immediate safety is the first priority in crisis intervention.
Choice B rationale:
Identifying social support is important but not the primary action in this situation.
Choice C rationale:
Instructing the client about coping skills is important, but immediate safety takes precedence.
Choice D rationale:
Exploring the client's perception of the event is valuable, but assessing for suicidality is more urgent.
Correct Answer is A
Explanation
Choice A rationale:
Tachycardia (rapid heart rate) is a common early indicator of excessive blood loss. It is the body's compensatory response to decrease in circulating blood volume.
Choice B rationale:
Flushed skin is not necessarily indicative of excessive blood loss. Pallor may be more characteristic.
Choice C rationale:
Polyuria (increased urine output) is not a reliable indicator of blood loss and is not commonly associated with postpartum hemorrhage.
Choice D rationale:
A firm fundus is a positive sign and indicates the uterus is contracting appropriately. It is not indicative of excessive blood loss.
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