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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale: Cloudy efluent doesn't necessarily indicate a need for emergency surgery unless accompanied by severe symptoms.

Choice B rationale: Cloudy efluent may indicate infection, so obtaining a culture and sensitivity test is crucial for appropriate treatment.

Choice C rationale: This step might be necessary if the efluent suggests infection, but sending a specimen for testing is the immediate priority.

Choice D rationale: This action isn't the first step; investigating the cause of cloudiness through testing is essential.

A. "Have you been experiencing any difficulty in achieving an erection?" B. "Have you noticed any unusual discharge from your penis?" C. "Has there been a decrease in the force of your urinary stream?" D. "Has there been any change in your sex life in the past year?"

Correct Answer is C

Explanation

Choice A rationale: This question is not relevant to BPH, as erectile dysfunction is not a common complication of this condition. Erectile dysfunction can have other causes, such as cardiovascular disease, diabetes, medications, psychological factors, or aging.

Choice B rationale: This question is not relevant to BPH, as penile discharge is not a symptom of this condition. Penile discharge can indicate an infection, such as sexually transmitted diseases, urinary tract infections, or prostatitis.

Choice C rationale: BPH is a condition that causes enlargement of the prostate gland, which can obstruct the flow of urine and cause symptoms such as difficulty in starting or stopping urination, weak or intermittent stream, dribbling, and incomplete bladder emptying. Asking about the force of the urinary stream can help assess the severity of BPH and the need for treatment.

Choice D rationale: This question is not relevant to BPH, as sexual function is not directly affected by this condition. However, some men with BPH may experience reduced libido or satisfaction due to urinary symptoms or psychological distress.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

Which question should the nurse ask when assessing a 60-year-old patient who has a history of benign prostatic hyperplasia (BPH)?

Correct Answer is C

Explanation

After reviewing the laboratory reports of a client, a nurse finds that the client has chronic pelvic inflammatory disorder (PID). Which condition should the nurse anticipate in the client?

A nurse is developing a plan of care for a client with a new diagnosis of Graves' disease. Which of the following interventions does the nurse include in the plan of care?

You are working in a Family Practice office. A patient comes into the office with right facial drooping. The physician makes a diagnosis of Bell's palsy. You know that the primary treatment for this disease is likely to include:

A nurse in a clinic is assessing a client. Which of the following findings should the nurse identify as a risk factor for osteoporosis?

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)

While assessing a male client, a nurse observes that the client has a small penis, long legs, short trunk, enlarged breast tissues, small testicles, and sexual dysfunction. What diagnosis does the nurse suspect from these findings?