A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain?

Changes in appetite

Prescribed medications

Daily fluid intake

wallowing ability

Answer and Explanation

The Correct Answer is D

A) Changes in appetite: While changes in appetite are important to assess, they are not the most immediate concern for a client with ALS who is experiencing weight loss. Appetite changes can contribute to weight loss, but other factors may be more critical.

B) Prescribed medications: Knowing the client’s prescribed medications is essential for overall care, but it is not the priority when addressing recent weight loss in a client with ALS. Medications can affect appetite and weight, but immediate physical concerns should be prioritized.

C) Daily fluid intake: Assessing daily fluid intake is important for hydration status, but it is not the priority in this scenario. Ensuring adequate fluid intake is necessary, but it does not directly address the potential complications related to weight loss in ALS.

D) Swallowing ability: Swallowing ability is the priority admission data to obtain for a client with ALS who has had recent weight loss. ALS can affect the muscles involved in swallowing, leading to dysphagia (difficulty swallowing). This can result in inadequate nutrition and hydration, as well as an increased risk of aspiration. Assessing swallowing ability helps identify the need for interventions such as dietary modifications, swallowing therapy, or alternative feeding methods to ensure the client’s safety and nutritional needs are met.

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Correct Answer is A

Explanation

A) Initiate droplet precautions: This is the correct answer. Epiglottitis can be caused by infections such as Haemophilus influenzae type b (Hib), which can spread through respiratory droplets. Implementing droplet precautions helps prevent the transmission of the infection to others.

B) Carefully suction the child's oropharynx to remove secretions: This intervention is risky in cases of epiglottitis because it may cause further airway obstruction or distress. It is generally avoided unless there is a clear indication that it is safe to do so.

C) Offer a high-calorie, high-protein diet: While nutrition is important, the immediate priority in a child with epiglottitis is to ensure airway patency and manage the infection, not dietary considerations.

D) Administer pancreatic enzymes with meals: This intervention is not relevant to epiglottitis, as pancreatic enzymes are typically indicated for conditions affecting digestion, such as cystic fibrosis or pancreatic insufficiency, rather than for an upper airway infection.

A. "I should expect the provider to evaluate the client within 4 hours of restraint application." B. "I should visually monitor the clit continuously when in mechanical restraints." C. "I should assess the client's skin integrity every 8 hours while in mechanical restraints." D. "I should ask the provider to write a prescription for mechanical restraints as needed."

Correct Answer is B

Explanation

A) “I should expect the provider to evaluate the client within 4 hours of restraint application.”:The provider must evaluate the client within a shorter timeframe, typically within 1 hour of applying mechanical restraints, to ensure the client’s safety and appropriateness of the intervention.

B) “I should visually monitor the client continuously when in mechanical restraints.”:Continuous visual monitoring is essential to ensure the client’s safety and well-being while in mechanical restraints. This allows for immediate intervention if any complications or distress arise.

C) “I should assess the client’s skin integrity every 8 hours while in mechanical restraints.”:Skin integrity should be assessed more frequently, typically every 2 hours, to prevent skin breakdown and other complications associated with prolonged use of restraints.

D) “I should ask the provider to write a prescription for mechanical restraints as needed.”:Mechanical restraints should not be used on an as-needed basis. They require a specific, time-limited order from a provider, and their use must be justified and documented according to strict guidelines and protocols.

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A home health nurse is assessing a client who has amyotrophic lateral sclerosis (ALS) and has had recent weight loss. Which of the following is the priority admission data for the nurse to obtain?

Nursing Test Bank

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Correct Answer is B

Explanation

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