A nurse is teaching a client who has amyotrophic lateral sclerosis (ALS) about the end stages of the disease process. Which of the following information should the nurse include in the teaching?
"You might wear splints over affected joints while you are sleeping."
"You will be given dexamethasone to treat muscle atrophy."
"You might require a machine to keep your airway open.
"You will receive nutrition through a central venous access device.
The Correct Answer is C
Choice A rationale:
Wearing splints over affected joints while sleeping is a strategy to prevent contractures, which are common in ALS.
Choice B rationale:
Dexamethasone is not used to treat muscle atrophy in ALS.
Choice C rationale:
As ALS progresses, clients may lose the ability to control their respiratory muscles, and a machine such as a ventilator may be required to assist with breathing.
Choice D rationale:
Nutrition through a central venous access device is not a standard intervention for ALS, as the focus is on preserving the client's ability to eat and swallow for as long as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Exhibiting grief response behaviors may indicate the client is processing emotions related to the assault but may not necessarily indicate effectiveness of the plan of care.
Choice B rationale:
Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.
Choice C rationale:
A sign of effectiveness in the plan of care for a client who has experienced sexual assault is the client's willingness to seek guidance and support in making important life decisions. This indicates a sense of trust in the nurse and a desire to move forward in a positive way.
Choice D rationale:
Demonstrating an increase in regressive behavior might indicate emotional distress but does not necessarily indicate effectiveness of the plan of care.
Correct Answer is C
Explanation
Choice A rationale:
Urine in acute glomerulonephritis often appears tea-colored or smoky due to hematuria.
Choice B rationale:
Hypertension is common in acute glomerulonephritis.
Choice C rationale:
Fluid retention and subsequent weight gain are common due to decreased kidney function.
Choice D rationale:
Hyponatremia is not typically associated with acute glomerulonephritis.
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