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?
Inappropriate laughter.
Asymmetrical weakness.
Increasing anxiety.
Weakened cough effort.
The Correct Answer is D
Weakened cough effort can lead to ineffective airway clearance and increase the risk of aspiration pneumonia, a common complication in ALS due to bulbar muscle involvement. Aspiration pneumonia is a serious and potentially life-threatening condition that requires immediate intervention
A This symptom can be distressing for the client and may impact their quality of life. While it should be addressed and managed, it does not pose an immediate threat to the client's physical health.
B Asymmetrical weakness is a hallmark feature of ALS, where muscle weakness typically begins in one region of the body and gradually spreads to other areas. While it signifies disease progression and may impact the client's mobility and function, it does not necessarily require immediate intervention.
C Anxiety is a common emotional response in clients with ALS, especially as the disease progresses and the client faces physical decline and uncertainty about the future. While it is important to address the client's emotional well-being and provide support, increasing anxiety does not usually warrant immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Wearing wrist braces or splints at night can help alleviate symptoms of carpal tunnel syndrome by keeping the wrists in a neutral position and reducing pressure on the median nerve. This can help decrease pain and tingling sensations that often worsen at night due to positioning during sleep.
A. While it is important for the client to communicate changes in symptoms to their healthcare provider, worsening pain and tingling at night in bilateral carpal tunnel syndrome is a common symptom and may not require immediate medical intervention.
C. Elevating the hands on two pillows at night may help reduce swelling and alleviate symptoms in some individuals, but it is not specifically indicated for managing carpal tunnel syndrome.
D. Cold compresses may provide temporary relief of symptoms such as pain and inflammation, but they are not typically recommended as a primary treatment for carpal tunnel syndrome, especially before bedtime.
Correct Answer is C
Explanation
C. Herpes zoster is caused by the reactivation of the varicella-zoster virus, the same virus that causes chickenpox (varicella). Asking whether everyone at home has already had varicella helps assess the risk of exposure to susceptible individuals who could potentially develop chickenpox upon exposure to the herpes zoster rash.
A. Sharing combs and brushes may increase the risk of transmitting head lice, fungal infections, or bacterial infections, but it is not directly relevant to the assessment of herpes zoster.
B. Dry patches on the feet and hands may be indicative of various dermatological conditions such as eczema or psoriasis, but they are not specific to herpes zoster. Herpes zoster typically presents as a painful rash with clusters of fluid-filled blisters along a specific dermatome
D. Asking about the effectiveness of antifungal creams is relevant if the client is being treated for a fungal infection, but it does not provide information specific to herpes zoster.
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