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 C

Explanation

A) Go to the emergency department:
An immediate trip to the emergency department is generally not required for a peak expiratory flow rate (PEFR) of 82%. The PEFR of 82% indicates that the client’s airflow is reduced, but it is not necessarily an emergency. PEFR readings are typically classified into zones: green (80-100% of personal best), yellow (50-79% of personal best), and red (below 50% of personal best). A reading of 82% is in the yellow zone, which suggests that the client is experiencing some degree of airway obstruction or worsening asthma symptoms

B) Continue to use salmeterol and fluticasone as prescribed:
While salmeterol (a long-acting beta agonist) and fluticasone (a corticosteroid) are important for long-term asthma control, continuing their use without additional intervention is not the most appropriate action when the PEFR is 82%. A PEFR of 82% indicates that the client’s asthma is not well controlled at the moment, and the nurse should recommend additional short-acting relief to help open the airways (e.g., a rescue inhaler like albuterol.

C) Administer an additional rescue dose of Albuterol:
The correct immediate action is to administer a rescue dose of albuterol. Albuterol is a short-acting beta-agonist that helps open the airways quickly during an asthma exacerbation. A PEFR of 82% falls in the yellow zone, suggesting some obstruction but not an emergency situation. In this case, administering an additional rescue dose of albuterol can help improve airflow and bring the PEFR closer to normal.

D) Call the physician:
While it may be necessary to call the physician if the client’s asthma symptoms do not improve after using a rescue inhaler or if there is a significant decline in symptoms, the first immediate action should be to use a rescue medication like albuterol. Calling the physician may be appropriate after assessing the response to the rescue medication, but it is not the first step in managing a PEFR of 82%.

A. Syncronized cardioversion B. Adenosine infusion over 30 minutes C. Immediate defibrillation D. Vagal manuevers

Correct Answer is A

Explanation

A. Synchronized cardioversion: Synchronized cardioversion is indicated for unstable supraventricular tachycardia (SVT), especially when the client shows signs of hemodynamic instability, such as hypotension, altered mental status, or chest pain. This intervention delivers a timed shock to restore normal rhythm, prioritizing the client's immediate stabilization.

B. Adenosine infusion over 30 minutes: Adenosine is typically administered as a rapid intravenous push to terminate SVT by temporarily blocking atrioventricular nodal conduction. However, this client is unstable, and synchronized cardioversion is the preferred intervention in cases of hemodynamic compromise.

C. Immediate defibrillation: Defibrillation is used for life-threatening arrhythmias like ventricular fibrillation or pulseless ventricular tachycardia. In this case, the rhythm is SVT, and the client is not in cardiac arrest, so defibrillation is inappropriate.

D. Vagal maneuvers: Vagal maneuvers, such as carotid sinus massage or the Valsalva maneuver, are first-line interventions for stable SVT. However, in unstable clients with severe symptoms or hemodynamic compromise, these measures are insufficient, and synchronized cardioversion is urgently required.

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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 nurse instructs a 60-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend to the client that obtains a reading of 82% on their peak flow meter?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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