The nurse is caring for a client who was recently diagnosed with ALS (Amyotrophic lateral sclerosis). Which of the following signs and symptoms is MOST important for the nurse to assess for?

Inability to void

Unable to eat without thickening meals

Loss of function in the lower extremity

Difficulty breathing

Answer and Explanation

The Correct Answer is D

A) Inability to void:
While urinary retention or difficulties with voiding can occur in ALS patients due to weakened muscles affecting the bladder, it is not the most immediate or life-threatening symptom that requires urgent attention. ALS primarily affects motor neurons and the voluntary muscles, and while autonomic dysfunction can lead to bladder or bowel issues, these are typically not the first concern in the acute phase of ALS unless they are severe.

B) Unable to eat without thickening meals:
Dysphagia (difficulty swallowing) is a common symptom in ALS, especially as the disease progresses and affects the muscles of the throat. While this symptom is important to address, it is manageable with interventions like speech therapy, modified diets, and thickened liquids

C) Loss of function in the lower extremity:
Loss of function in the lower extremities is a hallmark symptom of ALS as the disease progresses, but it is not an acute or life-threatening situation on its own. ALS leads to gradual muscle weakness and atrophy, particularly affecting voluntary motor functions.

D) Difficulty breathing:
As ALS progresses, respiratory muscles, including the diaphragm and intercostal muscles, weaken, which can lead to respiratory failure. The inability to breathe adequately can be life-threatening and may require interventions like mechanical ventilation, non-invasive positive pressure ventilation (BiPAP), or even a tracheostomy.

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Correct Answer is A

Explanation

A) Wear a dosimeter badge and lead apron when providing direct patient care: When caring for a patient undergoing internal radiation therapy (brachytherapy), radiation safety is the nurse’s priority. The nurse must take measures to minimize radiation exposure by wearing protective equipment such as a dosimeter badge (to monitor exposure levels) and a lead apron (to shield against radiation). These precautions are critical to protect healthcare workers from potential radiation harm while caring for a patient with a radiation implant.

B) Avoid placing a radiation sign at the entrance of the room for patient privacy: Placing a radiation warning sign at the entrance of the room is a mandatory safety protocol when a patient is undergoing brachytherapy. This warning sign informs healthcare personnel and visitors that radiation is present, and it is important for ensuring safety. Patient privacy should not override radiation safety protocols.

C) Alert family members that they should restrict their visiting to 60 minutes at a time: While it is essential to inform family members about safety precautions when visiting a patient receiving radiation therapy, the priority action for the nurse is to ensure their own safety and radiation exposure first. Limiting family visits is an important step to reduce unnecessary exposure, but this is a secondary concern compared to the nurse's direct radiation safety measures.

D) Explain to the patient that she will continue to emit radiation for months after the implant is removed: The patient will continue emitting radiation only for a short period after the implant is removed. The duration of radiation emission depends on the type of radioactive material used in brachytherapy, but it is typically limited to a few days or weeks at most. In most cases, the nurse would explain to the patient that, after the implant is removed, radiation emission will cease.

A. Use a razor to shave the hair in the treated area. B. Wash treated area gently with lukewarm water and mild soap. C. Purchase aloe approved skin-care products D. Wear loose-fitting, soft clothing over the treated skin. E. Sun tan the affected area for no more than 30 minutes a day

Correct Answer is ["B","C","D"]

Explanation

A) Use a razor to shave the hair in the treated area:
Shaving the treated area with a razor is not recommended during radiation therapy. The skin in the treated area becomes sensitive and fragile, so shaving could cause irritation, cuts, or abrasions. Instead, clients are usually advised to use electric razors or avoid shaving the area altogether. This instruction should not be followed to minimize the risk of injury.

B) Wash treated area gently with lukewarm water and mild soap:
This is a key self-care instruction for clients receiving radiation. Gentle cleansing with lukewarm water and mild soap helps to avoid further irritation to the skin, which can become dry and sensitive during radiation therapy. The treated area should not be scrubbed or rubbed, as this can cause damage to the skin, exacerbate dryness, or cause skin breakdown. This guideline is appropriate and should be followed.

C) Purchase aloe-approved skin-care products:
Using aloe vera or skin-care products approved for use during radiation therapy can help soothe and moisturize the skin, which often becomes dry, irritated, or sunburned from radiation. It is important to use products that are specifically designed for use during radiation to avoid any potential irritants or allergens. Aloe-based products or products recommended by the healthcare provider can provide relief and reduce side effects.

D) Wear loose-fitting, soft clothing over the treated skin:
Wearing loose-fitting, soft clothing is a crucial self-care recommendation for clients undergoing radiation. Tight or rough fabrics can irritate the sensitive skin, potentially leading to discomfort or skin breakdown. Soft fabrics like cotton are ideal, as they allow the skin to breathe and help avoid further friction or pressure on the treated area. This is an important aspect of skin protection during radiation therapy.

E) Sun tan the affected area for no more than 30 minutes a day:
Sun tanning or exposing the treated skin to direct sunlight is strictly forbidden during and after radiation therapy. The skin in the treated area is much more sensitive to UV radiation and can burn easily, even with minimal sun exposure. It can increase the risk of skin damage and delayed healing. The client should be advised to avoid direct sun exposure entirely and to wear protective clothing and sunscreen if they must be outdoors.

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The nurse is caring for a client who was recently diagnosed with ALS (Amyotrophic lateral sclerosis). Which of the following signs and symptoms is MOST important for the nurse to assess for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with uterine cancer is being treated with internal radiation herapy (brachytherapy). What is the nurse's PRIORITY action when caring for this client?

Correct Answer is A

Explanation

A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which self-care instructions can the nurse provide the client receiving radiation? [Select all that apply.]

Correct Answer is ["B","C","D"]

Explanation

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