The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

The person's cognitive and mental capacity will most likely remain intact throughout the disease progression.

The person's ability to swallow will remain intact throughout the disease.

The person's risk for seizures increases with progression of the disease.

The person's breathing will not be affected by the disease.

Answer and Explanation

The Correct Answer is A

Choice A reason: ALS is a neurodegenerative disease that affects the motor neurons, which control the voluntary muscles. It does not affect the cognitive or mental functions, such as memory, reasoning, or emotions. Therefore, the person with ALS will be aware of their condition and their surroundings, even when they lose their ability to move, speak, or breathe.

Choice B reason: ALS affects the muscles of the mouth, throat, and chest, which are involved in swallowing. As the disease progresses, the person with ALS will have difficulty swallowing food, liquids, and saliva. This can lead to malnutrition, dehydration, choking, and aspiration pneumonia.

Choice C reason: ALS does not directly cause seizures, which are abnormal electrical activity in the brain. However, some medications used to treat the symptoms of ALS, such as muscle relaxants, may increase the risk of seizures. Therefore, the person with ALS should be monitored for any signs of seizures, such as loss of consciousness, convulsions, or confusion.

Choice D reason: ALS affects the muscles of the diaphragm and the intercostal muscles, which are involved in breathing. As the disease progresses, the person with ALS will have difficulty breathing, especially at night or when lying down. This can lead to respiratory failure, which is the most common cause of death in ALS. Therefore, the person with ALS may need mechanical ventilation or noninvasive positive pressure ventilation to support their breathing.

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Correct Answer is A

Explanation

Choice A reason: Maintaining pressure to the puncture site and observing for drainage is the priority nursing intervention for a patient who had a lumbar puncture. It helps to prevent bleeding, hematoma, and cerebrospinal fluid leakage, which can cause complications such as infection, headache, or nerve damage.

Choice B reason: Completing a pain assessment and administering an ordered analgesic, as needed, is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause mild to moderate pain and discomfort at the puncture site, which can be relieved by analgesics, ice packs, or massage.

Choice C reason: Informing the patient they may feel pressure and sharp pain in their lower back for several hours is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause transient sensations of pressure and pain in the lower back, which can be reduced by lying flat, avoiding sudden movements, and drinking fluids.

Choice D reason: Assessing pulses distal to the lumbar puncture site every two hours is not an appropriate nursing intervention for a patient who had a lumbar puncture. Lumbar puncture does not affect the blood circulation to the lower extremities, unless there is a complication such as hematoma or nerve compression. Therefore, the nurse should monitor the neurological status, vital signs, and signs of infection or bleeding.

A. Presence of a synthetic silicone mesh stent in a coronary artery. B. Allergy to shellfish and iodine. C. Contact lenses. D. Presence of an internal insulin pump in the abdomen.

Correct Answer is D

Explanation

Choice A reason: Presence of a synthetic silicone mesh stent in a coronary artery is not a contraindication for MRI. Silicone is a non-magnetic material that does not interfere with the magnetic field or cause any harm to the patient or the device.

Choice B reason: Allergy to shellfish and iodine is not a contraindication for MRI. Shellfish and iodine are not related to the contrast agent used for MRI, which is usually gadolinium. However, the patient should inform the provider if they have any history of allergic reactions to contrast agents or any other medications.

Choice C reason: Contact lenses are not a contraindication for MRI. Contact lenses are made of plastic or silicone, which are non-magnetic materials that do not interfere with the magnetic field or cause any harm to the patient or the device. However, the patient should remove them before the procedure to avoid any discomfort or irritation.

Choice D reason: Presence of an internal insulin pump in the abdomen is a contraindication for MRI. Insulin pumps are electronic devices that contain metal parts, batteries, and wires, which can be affected by the magnetic field and cause malfunction, damage, or injury to the patient or the device. Therefore, the patient should inform the provider and the MRI technician about the insulin pump and follow their instructions on how to manage it before, during, and after the procedure.

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The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient undergoing a lumbar puncture by the provider. Select the priority nursing intervention the nurse would complete after the procedure.

Correct Answer is A

Explanation

The nurse completes a focused assessment and history of a patient who is scheduled for magnetic resonance imaging (MRI). Which data shared by the patient would the nurse need to contact the provider?

Correct Answer is D

Explanation

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