While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?
Increasing anxiety.
Inappropriate laughter.
Asymmetrical weakness.
Weakened cough effort.
The Correct Answer is D
A. Increasing anxiety may require intervention, but it does not pose an immediate threat to the client's health compared to other options.
B. Inappropriate laughter could indicate emotional lability, a common symptom in ALS, but it does not typically require immediate intervention unless it's accompanied by other concerning symptoms.
C. Asymmetrical weakness is common in ALS but may not necessarily warrant immediate intervention unless it is significantly affecting the client's ability to perform essential functions.
D. Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sipping fluids with each meal may help prevent dehydration and promote hydration but is not the most important dietary instruction post-gastric bypass surgery.
B. Chewing slowly and thoroughly is important for digestion but is not specific to post-gastric bypass dietary needs.
C. Reducing intake of fatty foods is important for overall health but is not the most critical dietary instruction post-gastric bypass surgery.
D. Eating small frequent meals is crucial after gastric bypass surgery to prevent complications such as dumping syndrome, promote adequate nutrient absorption, and manage portion sizes effectively.
Correct Answer is A
Explanation
A. Wearing braces on both wrists during the night can help maintain a neutral wrist position and alleviate pressure on the median nerve, reducing symptoms of carpal tunnel syndrome.
B. Notifying the healthcare provider may be necessary if symptoms worsen or if additional interventions are needed, but this is not the first-line intervention for managing symptoms at night.
C. Elevating the hands on two pillows at night may provide some relief, but it is not as effective as wearing wrist braces to maintain proper alignment and reduce pressure on the median nerve.
D. Applying cold compresses before bedtime may help reduce inflammation but is not specifically targeted at alleviating nighttime symptoms of carpal tunnel syndrome.
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