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 D

Explanation

A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient.

B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding.

C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts.

D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.

A. Assess for increasing fluid volume overload. B. Withhold next scheduled dose of treatment. C. Increase neurologic checks to every 2 hours. D. Maintain the prescribed fluid restriction.

Correct Answer is D

Explanation

A. Assessing for increasing fluid volume overload is not indicated with a rising serum sodium level; instead, it suggests correction of hyponatremia, a common complication of SIADH.

B. Withholding the next scheduled dose of treatment is not appropriate based solely on a rise in serum sodium level within the normal range.

C. Increasing neurologic checks may be necessary in severe cases of hyponatremia but is not directly indicated by a rise in serum sodium within the normal range.

D. Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.

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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

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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