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?

Swallowing ability

Changes in appetite

Prescribed medications

Daily fluid intake

Answer and Explanation

The Correct Answer is A

A: Swallowing ability is crucial because ALS often leads to dysphagia, which can cause weight loss due to difficulty eating and the risk of aspiration.
B: Changes in appetite are important but secondary to physical ability to eat safely.

C: While knowing about prescribed medications is necessary, it does not directly address the issue of weight loss as critically as swallowing ability.
D: Fluid intake is important but the priority is assessing the ability to swallow safely, which directly impacts nutritional status.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. When assessing skin turgor in older adults, it is recommended to perform the test over the sternum or on the forehead. This is due to the fact that many older adults have reduced skin turgor as a part of the typical aging process, which can make it difficult to use the test to determine dehydration accurately in other areas.
B. In the elderly, skin turgor assessment on the abdomen can be influenced by factors such as adipose tissue and may not provide as reliable an indicator.

C. The shoulder is not commonly used for assessing skin turgor and may not provide reliable results.
D. The neck is not typically used for assessing skin turgor and may not provide an accurate reflection of hydration status.

A. Provocative behavior B. Lack of empathy C. Goal-oriented D. Lability

Correct Answer is C

Explanation

A. This is not characteristic of OCPD; such behavior is more associated with personality disorders that involve issues with impulse control and attention-seeking, such as histrionic personality disorder.
B. While people with OCPD might appear rigid or stubborn, a lack of empathy is more characteristic of antisocial or narcissistic personality disorders.
C. Individuals with obsessive-compulsive personality disorder (OCPD) are often highly focused on orderliness, perfectionism, and control, making them very goal- oriented and preoccupied with productivity.
D. Emotional lability is not a feature of OCPD; it is more often associated with borderline personality disorder, which includes rapid and intense emotional swings.

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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

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