A client is discharged to home following hospitalization for percutaneous endoscopic gastrostomy tube placement to assist with nutrition. The client's primary diagnosis is amyotrophic lateral sclerosis (ALS). The client can transfer from the bed to a chair but can't walk.
The client and their family are concerned about the client's ability to maintain mobility at the highest possible level following a surgical procedure. The nursing diagnosis most appropriate for this client is ...
Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate.
Hopelessness related to impaired ability to cope.
Caregiver role strain related to care recipient's unrealistic expectations of caregiver.
Impaired memory related to reduced quality and quantity of information processed.
The Correct Answer is A
Choice A rationale: In ALS, impaired physical mobility due to decreased motor agility and the inability to ambulate is a direct consequence of the disease.
Choice B rationale: Hopelessness might be a possible emotional response but doesn't address the client's physical limitations due to ALS.
Choice C rationale: Caregiver role strain is related to the family's ability to manage caregiving responsibilities and is not the primary concern for the client's physical mobility.
Choice D rationale: Impaired memory is not the primary issue in ALS; the client's inability to ambulate due to decreased motor function is the main focus for this nursing diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The Tensilon test involves injecting edrophonium, and in myasthenia gravis, temporary improvement in muscle strength confirms the diagnosis by demonstrating increased acetylcholine activity at the neuromuscular junction.
Choice B rationale: This describes the pathophysiology of myasthenia gravis but doesn’t directly confirm the diagnosis via the Tensilon test.
Choice C rationale: While this may be seen in myasthenia gravis, the Tensilon test specifically aims to observe improved muscle strength after administration.
Choice D rationale: While the presence of these antibodies is a characteristic of myasthenia gravis, the Tensilon test is used to assess the immediate response to the medication for diagnostic confirmation.
Correct Answer is D
Explanation
Choice A rationale: A breast lump that increases in size before the menstrual period might be related to hormonal changes and is not necessarily indicative of a concerning issue.
Choice B rationale: Bilateral breast nodules that are tender with palpation might be related to benign conditions or hormonal changes.
Choice C rationale: A small, mobile, rubbery breast lump could suggest a benign condition like a fibroadenoma, which might not be as concerning.
Choice D rationale: A breast nodule that is 1 cm in size, nontender, and fixed could potentially raise concerns about malignancy and requires further evaluation.
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