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 C
Explanation
Choice A rationale: This symptom typically indicates secondary syphilis, not gonorrhea.
Choice B rationale: Warts on the genitals suggest a different sexually transmitted infection caused by HPV, not gonorrhea.
Choice C rationale: A discharge from the penis is a common symptom of gonorrhea and often prompts individuals to seek medical attention.
Choice D rationale: While discomfort can be associated with gonorrhea, the primary presenting symptom often involves discharge rather than specific lesions.
Correct Answer is D
Explanation
Choice A rationale: Expressive aphasia is a type of non-fluent aphasia that affects the
ability to produce language. It is caused by damage to the anterior part of the left frontal lobe, which is responsible for motor planning and execution of speech. Patients with expressive aphasia can understand language but have difficulty speaking, writing, or naming objects. They often produce short, halting, and grammatically incorrect sentences with word-finding difficulties.
Choice B rationale: this is another term for expressive aphasia. The patient can
understand language but have difficulty speaking, writing, or naming objects. They often produce short, halting, and grammatically incorrect sentences with word-finding difficulties.
Choice C rationale: Global aphasia is a severe form of aphasia that affects both
comprehension and production of language. It is caused by extensive damage to the left hemisphere of the brain, which is dominant for language functions in most people.
Patients with global aphasia have little or no ability to speak, write, read, or understand language.
Choice D rationale: Wernicke's aphasia is a type of receptive aphasia that affects the
comprehension and production of language. It is caused by damage to the posterior part of the left temporal lobe, which is responsible for processing auditory and visual
information. Patients with Wernicke's aphasia can speak fluently but nonsensically, using words that are irrelevant, invented, or distorted. They also have difficulty understanding spoken or written language and following commands.
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