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 B

Explanation

A) Take magnesium hydroxide for indigestion: This is not advisable for a client with chronic kidney disease (CKD) because magnesium can accumulate and lead to toxicity in individuals with impaired kidney function. Therefore, the nurse should recommend avoiding magnesium-based antacids.

B) Eat 1 g/kg of protein per day: This statement is correct. Clients on hemodialysis often require a higher protein intake to compensate for protein losses during dialysis. However, protein intake should be carefully monitored and tailored to individual needs and dialysis status.

C) Consume foods high in potassium: This instruction is inappropriate for a client with CKD. Elevated potassium levels (hyperkalemia) can be dangerous for these clients, so they should limit high-potassium foods to prevent complications.

D) Drink at least 3 L of fluid daily: This recommendation is not suitable for clients on hemodialysis, as fluid intake is typically restricted to prevent fluid overload. Fluid needs should be assessed based on the individual's condition and urine output, but generally, they should not drink excessive amounts.

A. "I will use the results of this test daily to modify my insulin dosage." B. "I will need to drink a glucose solution to get an accurate result." C. "I will use this test to monitor how well I control my blood glucose levels." D. "I will need to fast prior to taking this test."

Correct Answer is C

Explanation

A) Using the results of the glycosylated hemoglobin (HbA1c) test daily to modify insulin dosage is not accurate. The HbA1c reflects average blood glucose levels over the past 2-3 months and is not intended for immediate adjustments to insulin therapy.

B) Drinking a glucose solution is not necessary for the HbA1c test. This test measures the percentage of hemoglobin that is glycated and does not require any specific preparation like glucose ingestion.

C) Using this test to monitor how well blood glucose levels are controlled is accurate. The HbA1c test provides a long-term view of blood glucose control, helping both the client and healthcare provider assess the effectiveness of diabetes management strategies over time.

D) Fasting is not required prior to the HbA1c test. Unlike other glucose tests, the HbA1c can be performed at any time without fasting, making it a convenient option for ongoing monitoring.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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