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 B
Explanation
Choice A rationale: Her healthcare provider prescribing a calcium channel blocker for hypertension is not directly linked to lymphedema.
Choice B rationale: Sustaining an insect bite to her left arm yesterday - Trauma or injury, such as an insect bite, to the affected limb post-mastectomy can increase the risk of
lymphedema.
Choice C rationale: Losing twenty pounds since the surgery might influence overall health but doesn’t specifically relate to lymphedema.
Choice D rationale: Her hobby of playing classical music on the piano is unrelated to the risk of developing lymphedema.
Correct Answer is C
Explanation
Choice A rationale: Typically associated with potassium depletion rather than elevated levels.
Choice B rationale: Furosemide, a loop diuretic, can cause potassium depletion leading to hypokalemia, but it might also cause transient elevations in potassium levels initially. Choice C rationale: Addison disease can cause hyperkalemia, or high potassium, due to decreased renal excretion of potassium and increased retention of sodium and water.
Choice D rationale: Cushing disease can cause hypokalemia, or low potassium, due to increased renal excretion of potassium and decreased reabsorption of sodium and water.
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