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.

Answer and Explanation

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.

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Correct Answer is []

Explanation

Potential condition: Retinopathy

Actions to take: Orient the client to the environment; Call for an ophthalmological exam

Parameters to monitor: Blood glucose; Visual acuity

Rationale:

Based on the patient data provided, the client is most likely experiencing retinopathy, particularly diabetic retinopathy, which is a common complication of diabetes and can lead to progressive vision loss. The elevated HBA1C level indicates poor blood glucose control, which can contribute to the worsening of this condition.

The nurse should call for an ophthalmological exam to confirm the diagnosis and assess the extent of retinal damage. Additionally, orienting the client to the environment is important to ensure safety due to the vision impairment. Monitoring the client's blood glucose levels is crucial for managing his diabetes and potentially stabilizing or improving the retinopathy.

Visual acuity should also be monitored to track any changes in vision and the effectiveness of interventions. It is essential to manage the underlying diabetes effectively to prevent further progression of retinopathy.

A. Restrict protein intake by limiting meats and other high protein foods. B. Increase intake of high fiber foods, such as bran cereal. C. Limit oral fluid intake to 500 mL/day. D. Increase intake of potassium rich foods such as bananas or cantaloupe.

Correct Answer is A

Explanation

A. Restricting protein intake is often recommended for clients with glomerulonephritis to reduce the workload on the kidneys and decrease proteinuria. This can help slow the progression of kidney damage.

B. Increasing intake of high-fiber foods may be beneficial for overall health but is not specifically indicated for glomerulonephritis management.

C. Limiting oral fluid intake to 500 mL/day is not appropriate for most clients and may lead to dehydration, which can exacerbate kidney dysfunction.

D. Increasing intake of potassium-rich foods may be contraindicated in some cases of glomerulonephritis, especially if the client has hyperkalemia. Dietary potassium restriction may be necessary depending on the client's lab values and kidney function.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendation should the nurse encourage the client to follow?

Correct Answer is A

Explanation

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