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 A
Explanation
A. Large soaking tub without a shower head: This poses a potential risk for injury. A large soaking tub can make it difficult for the client to safely enter and exit, increasing the risk of falls, especially after a total hip arthroplasty.
B. No stairs in the home: This is actually a positive finding, as having no stairs reduces the risk of falls and injury for the client during their recovery.
C. Elevated toilet seats: Elevated toilet seats are generally considered beneficial for clients recovering from hip surgery, as they make it easier to sit down and stand up, reducing strain on the hip.
D. Reclining chair with a straight back: This is also a positive finding. A reclining chair can provide comfort and support, and a straight back can promote proper posture during recovery.
Correct Answer is A
Explanation
A) Ensure that all area rugs are rubber-backed:Rubber-backed rugs help prevent slips and falls by keeping the rugs securely in place on the floor. This is particularly important for someone recovering from knee surgery to avoid additional injury and ensure a safe home environment.
B) Wear slippers with cloth soles:Slippers with cloth soles can be slippery and increase the risk of falls. It is safer to wear slippers with non-slip soles to provide better traction and stability.
C) Place a towel on the floor outside of the shower:Placing a towel on the floor can create a slipping hazard. Instead, using a non-slip bath mat outside the shower is recommended to prevent falls.
D) Place a handrail in the entryway of the house:While placing a handrail in the entryway can be beneficial, it is not as immediately critical as ensuring that area rugs are rubber-backed to prevent falls throughout the home. Handrails are more commonly recommended for stairs and bathrooms.
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