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 D
Explanation
Choice A rationale: Biopsy during an endoscopy can help confirm the presence of duodenal ulcers by analyzing tissue samples.
Choice B rationale: Urea breath test is used to detect the presence of Helicobacter pylori, a bacterium associated with duodenal ulcers.
Choice C rationale: Endoscopy is a standard procedure for diagnosing duodenal ulcers by directly visualizing the upper gastrointestinal tract.
Choice D rationale: While a CT scan can be useful in some cases, it's less commonly used for diagnosing duodenal ulcers compared to other diagnostic methods like endoscopy,
biopsy, or urea breath test.
Correct Answer is A
Explanation
Choice A rationale: Hypoglycemia (blood sugar less than 30 mg/dL) can lead to seizures due to inadequate glucose supply to the brain.
Choice B rationale: Anorexia (loss of appetite) is not directly associated with low blood sugar but can be a symptom of other conditions.
Choice C rationale: Anhidrosis refers to the inability to sweat and is not typically associated with low blood sugar.
Choice D rationale: Bradycardia (slow heart rate) can be a symptom of severe hypoglycemia but is not the primary complication expected at this blood sugar level.
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