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 C

Explanation

A) Taking your temperature 1 hour after getting out of bed is not appropriate for the basal body temperature method. For accurate tracking, temperature should be taken immediately upon waking, before any activity or movement that could affect the reading.

B) Taking your temperature every night before going to bed does not align with the basal body temperature method. This method requires consistent morning measurements to track ovulation accurately, as body temperature can fluctuate throughout the day.

C) Taking your temperature immediately after waking and before getting out of bed is the correct instruction. This ensures the reading reflects the body's resting temperature, which can help identify the slight increase that occurs after ovulation, aiding in family planning efforts.

D) Taking your temperature within 30 minutes after your first morning void is not suitable for this method. The ideal time is right upon waking, and any activity, including using the bathroom, can alter body temperature and lead to inaccurate readings.

A. Noting changes in the treatment plan in the client's medical record B. Recording the client's progress in the nurses' notes C. Posting swallowing precautions at the head of the client's bed D. Having interdisciplinary team meetings for the client on a regular basis

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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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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