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

Weakened cough effort

Asymmetrical weakness

Answer and Explanation

The Correct Answer is C

A. Increasing anxiety:
While emotional and psychological aspects are important in holistic care, immediate intervention is usually required for physiological concerns. Increasing anxiety may need attention, but it is not as urgent as addressing potential respiratory issues.

B. Inappropriate laughter:
Changes in emotional expression, such as inappropriate laughter, can occur in ALS due to involvement of upper motor neurons. While notable, it may not be as urgent as addressing respiratory concerns.

C. Weakened cough effort.
In ALS, respiratory muscles can become affected as the disease progresses, leading to respiratory complications. Weakened cough effort is concerning because it can indicate potential respiratory muscle weakness, which may lead to difficulty clearing secretions and an increased risk of respiratory compromise or infection.

D. Asymmetrical weakness:
Asymmetrical weakness is a common feature of ALS, but it may not necessarily warrant immediate intervention unless there are sudden changes or signs of acute distress. Respiratory symptoms, such as weakened cough effort, often require more immediate attention.

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Correct Answer is ["B","D"]

Explanation

A. Use standard precautions and wear a mask:
The use of standard precautions is appropriate for general care to prevent the transmission of infectious agents. However, specific to MRSA, additional precautions are needed. Wearing a mask is generally not necessary unless the client has respiratory symptoms that warrant respiratory precautions.

B. Institute contact precautions for staff and visitors:
This is a correct intervention. Contact precautions involve using gowns and gloves when providing care to prevent the transmission of MRSA. It is important for both healthcare staff and visitors to adhere to contact precautions to reduce the risk of spreading the infection.

C. Explain the purpose of a low bacteria diet:
The purpose of a low bacteria diet is generally unrelated to the management of MRSA. Low bacteria diets are often recommended for individuals with compromised immune systems to reduce the risk of foodborne infections. However, it may not be directly applicable to MRSA management.

D. Monitor the client's white blood cell count:
Monitoring the white blood cell count is a relevant intervention. An elevated white blood cell count may indicate an ongoing infection or an inflammatory response. Regular monitoring helps assess the client's immune response and the potential severity of the infection.

A. Drink at least 8 cups (1920 mL) of water per day. B. Eat high protein foods to achieve ideal body weight C. Encourage active range of motion to limit stiffness. D. Use electric heating pad when pain is at its worse.

Correct Answer is A

Explanation

A. Drink at least 8 cups (1920 mL) of water per day:
This is the correct answer. Adequate hydration is important in the management of gout because it helps to flush out uric acid and prevent the formation of urate crystals. Increasing fluid intake, especially water, is a key component of gout management.

B. Eat high protein foods to achieve ideal body weight:
While maintaining a healthy weight is important in managing gout, the emphasis should be on a balanced diet that includes adequate hydration and avoidance of foods high in purines, which can contribute to increased uric acid levels.

C. Encourage active range of motion to limit stiffness:
Active range of motion exercises can be beneficial for joint health, but the primary emphasis in gout management is on dietary and pharmacological interventions.

D. Use an electric heating pad when pain is at its worse:
Applying heat may provide some relief, but it is not the primary intervention for gout. Cold compresses or ice may be more appropriate for acute gout attacks.

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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

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Correct Answer is ["B","D"]

Explanation

Correct Answer is A

Explanation

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