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) “I will need to keep my hand elevated above my heart for several days.”: Elevating the hand above the heart helps reduce swelling and pain after surgery. This practice is crucial for promoting proper healing and minimizing discomfort.

B) “I should expect numbness and tingling in my hand.”: Numbness and tingling are not expected outcomes and could indicate complications. These symptoms should be reported to the healthcare provider for further evaluation.

C) “I should not use my affected hand for 4 to 6 weeks.”: Complete restriction of hand use for 4 to 6 weeks is unnecessary and could lead to stiffness and decreased function. Gradual use and movement are encouraged to aid recovery.

D) “I can apply heat for the first 24 hours to minimize the pain in my hand.”: Applying heat in the first 24 hours can increase swelling and should be avoided. Cold therapy is recommended initially to reduce inflammation and pain.

A. Perform exercises prior to bedtime. B. Stay in bed at least 1 hr if unable to fall asleep. C. Eat a light snack before bedtime. D. Take a 1-hr nap during the day.

Correct Answer is C

Explanation

A) Perform exercises prior to bedtime: Engaging in vigorous exercise right before bedtime can actually be stimulating and may interfere with the ability to fall asleep. It is generally recommended to complete exercise earlier in the day to promote better sleep.

B) Stay in bed at least 1 hr if unable to fall asleep: This practice can lead to increased frustration and anxiety about sleep. Instead, it is often advised to get out of bed and engage in a calming activity until feeling sleepy again, which can help reduce sleep anxiety.

C) Eat a light snack before bedtime: Consuming a light snack can be beneficial, as certain foods (like those containing tryptophan) may promote sleepiness. It is important to avoid heavy meals, but a small snack can help some individuals feel more comfortable and ready for sleep.

D) Take a 1-hr nap during the day: While napping can be beneficial, a long nap may interfere with nighttime sleep, especially if taken later in the day. It’s generally better to keep naps short (20-30 minutes) and earlier in the day to avoid impacting nighttime sleep quality.

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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?

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