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 ["0.4"]
Explanation
To determine the correct dosage, the nurse needs to perform a calculation using the information provided. The prescription is for 200,000 units of penicillin, and the available vial concentration is 500,000 units per mL.
To find out how many mLs to administer, the nurse would divide the prescribed units by the concentration of units per mL. This is calculated as 200,000 units divided by 500,000 units/mL, which equals 0.4 mL.
Correct Answer is C
Explanation
A. Fentanyl and hydromorphone are potent opioids often used for pain management, but they are not typically first-line medications for acute chest pain associated with suspected myocardial infarction.
B. Hydromorphone, like fentanyl, is an opioid analgesic primarily used for moderate to severe pain but is not the first choice for managing acute chest pain.
C. Morphine is the medication of choice for managing acute chest pain associated with myocardial infarction. It helps alleviate pain, reduce myocardial oxygen demand, and relieve anxiety.
D. Oxycodone is an opioid analgesic used for moderate to severe pain but is not typically indicated as first-line therapy for acute chest pain associated with myocardial infarction.
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