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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Ensuring that the client's family supports the provider's decision for surgery is important, but it is secondary to confirming that the healthcare surrogate is informed about the risks and benefits. The family’s emotional support is valuable, but informed consent is paramount.
B) Determining if the client's health care surrogate is aware of the risks and benefits of the procedure is crucial. Since the client is in a coma and unable to provide informed consent, the surrogate must be fully informed to make appropriate decisions regarding the client's care. This ensures that the rights and wishes of the client are upheld.
C) Sending the unsigned informed consent form to the facility's risk manager may be a procedural step in some situations, but it does not directly address the immediate need for informed consent or ensure that the healthcare surrogate understands the implications of the procedure. This action can be part of post-decision documentation but is not the first priority.
D) Determining if the procedure is medically necessary is important; however, the immediate concern is ensuring that informed consent is obtained from the health care surrogate. Understanding the necessity of the procedure can be part of the discussion with the surrogate but does not replace the need for informed consent.
Correct Answer is D
Explanation
A) Noting changes in the treatment plan in the client's medical record: While this is important for continuity of care, it may not directly facilitate communication among staff in real-time or promote a collaborative approach.
B) Recording the client's progress in the nurses' notes: Documenting progress is essential, but it serves more as a record of care rather than an active communication tool among the team members.
C) Posting swallowing precautions at the head of the client's bed: This helps ensure that all staff are aware of the precautions, but it does not promote a broader dialogue about the client's overall care and communication needs.
D) Having interdisciplinary team meetings for the client on a regular basis: This is the correct answer. Regular interdisciplinary meetings encourage collaborative communication, allowing various healthcare professionals to discuss the client’s needs, share observations, and develop a cohesive care plan, which is especially important for clients with communication barriers like expressive aphasia.
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