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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale: The correct answer is 5 units/hour. To calculate the units of insulin per hour, we need to use the following formula: units of insulin per hour = (units of insulin in the bag / volume of the bag) x infusion rate

Plugging in the given values, we get:

units of insulin per hour = (50 / 100) x 10 units of insulin per hour = 0.5 x 10

units of insulin per hour = 5

Therefore, the client is receiving 5 units of insulin every hour.

Choice B rationale: This is incorrect because it assumes that the infusion rate is equal to the units of insulin per hour, which is not true.

Choice C rationale: This is incorrect because it multiplies the units of insulin in the bag by the infusion rate, which is too high.

Choice D rationale: This is incorrect because it adds the units of insulin in the bag and the infusion rate, which is also too high.

A. Creatinine, 0.9 mg/dL B. White blood cell count, 11,500 mm" C. BUN 26 mg/dL. D. Reports of pain increasing while coughing E. Potassium 3.3 mEq/L F. Nausea and vomiting

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

Explanation

Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.

Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.

Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.

Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.

Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.

Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.

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Naxlex Comprehensive Predictor Exams

A client is receiving 10 mL/hr of a prescribed regular insulin infusion. The label on the bag reads 50 units of regular insulin in 100 mL of 0.9% saline. How many units of insulin is the client receiving every hour? Fill in the blank. Round your answer to the nearest whole number.

Correct Answer is A

Explanation

The nurse is caring for a client who presents with acute appendicitis: Exhibits Select all that apply?

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

Explanation

Which of the following describes the correct procedure for testing for Kernig's sign?

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A nurse notes that a client's serum potassium level is 5.9 mEq/L. The nurse interprets this as an expected finding in the client with:

A client tells the nurse, "I have intense stomach pain for 3 hours after eating." On assessment the nurse finds abdominal pain and tenderness of the abdomen. The nurse suspects duodenal ulcers in the client. Which diagnostic procedure does the primary health-care provider least likely recommend?

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

When providing care for a client receiving peritoneal dialysis. While draining the dialysate the nurse notices that the efluent is cloudy. Which intervention is most important for the nurse to carry out at this moment?