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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Hypertension:

Hypertension is not directly related to the rhythm displayed in the image. The rhythm is suggestive of atrial fibrillation (AF), characterized by irregular and chaotic electrical activity, leading to irregular heartbeats. Hypertension can be a risk factor for AF but is not a typical presenting symptom.

B. Indigestion:

Indigestion is a non-specific symptom that may occur in cardiac events like myocardial infarction but is not a hallmark of atrial fibrillation. The rhythm strip does not indicate myocardial ischemia.

C. Eupnea:

Eupnea refers to normal breathing, which is not commonly associated with atrial fibrillation. Clients with AF may experience symptoms such as shortness of breath or fatigue rather than normal, unlabored breathing.

D. Irregular palpitations:

This is the most expected finding. Atrial fibrillation leads to an irregularly irregular pulse, which patients often describe as palpitations. This rhythm strip demonstrates the hallmark chaotic atrial activity and irregular ventricular response seen in AF.

A. A normal finding. B. A myasthenia gravis crisis due to drug undermedication C. An allergic reaction. D. A cholinergic crisis due to drug overmedication

Correct Answer is D

Explanation

A) A normal finding:
A normal finding during an edrophonium (Tensilon) test is an improvement in muscle strength for clients with myasthenia gravis (MG). If the client becomes weaker after the dose, it indicates that the test results are not typical and suggest a different issue, not a normal response. This is not a normal finding.

B) A myasthenia gravis crisis due to drug undermedication:
In a myasthenic crisis, the client experiences severe weakness and respiratory difficulty, typically due to insufficient medication (e.g., pyridostigmine). While a myasthenic crisis could cause weakness and respiratory distress, the edrophonium test would typically show improvement in muscle strength if the crisis is due to undermedication. Since the client became weaker after receiving edrophonium, this is not indicative of a myasthenic crisis.

C) An allergic reaction:
An allergic reaction to the edrophonium test would typically result in symptoms such as rash, swelling, or difficulty breathing due to hypersensitivity, but it does not typically cause weakness as the primary response. The worsening of symptoms after the test is more likely related to drug overmedication rather than an allergic reaction.

D) A cholinergic crisis due to drug overmedication:
A cholinergic crisis occurs when there is an overdose of acetylcholinesterase inhibitors (e.g., pyridostigmine or neostigmine), which can lead to excessive acetylcholine at the neuromuscular junction, resulting in muscle weakness and respiratory failure. The edrophonium test helps differentiate between a myasthenic crisis and a cholinergic crisis. If the client becomes weaker after the administration of edrophonium, it suggests a cholinergic crisis due to drug overmedication.

View Question and Answer

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

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 the rhythm below has been admitted into the cardiac icu. What assessment finding does the nurse expect to find in this client?

Correct Answer is D

Explanation

A client with history of myasthenia gravis is experiencing prolonged periods of weakness and difficulty breathing. The provider orders an edrophonium [Tensilon] test. Once the dose is administered, the client becomes weaker. The nurse interprets this test result as:

Correct Answer is D

Explanation

A senior nurse is providing instructions to a newly hired nurse about caring for clients who are receiving diuretic therapy to treat heart failure. The senior nurse should explain that which of the following medications puts clients at risk for both hyperkalemia and hyponatremia?

A nurse is caring for a group of clients on a hospital unit with the assistance of a licensed practical nurse [LPN]. Which aspect of client care would be the most appropriate for the nurse to delegate to the LPN?

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include?

A nurse is assessing a client who has early symptoms of hypoxia. Which of the following findings should the nurse expect?

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require immediate intervention?

A client with Parkinson's disease is prescribed carbidopa-levadopa [Sinemet]. Which of the following side effects does the nurse recognize can occur with this medication?

The nurse is preparing discharge teaching for a client who is recently diagnosed with Multiple sclerosis. Which of the following is the most important to include in the patient teaching?

A client with COPD exacerbation has been ordered oral prednisone to be tapered over two weeks. Which of the following side effects does the nurse recognize could occur during prednisone therapy? [Select all that apply.]