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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Correct Answer is B

Explanation

A: Heparin administration requires careful monitoring of clotting times, so discharging this client early may not be safe or appropriate.
B: A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
C: This client has a respiratory rate suggestive of respiratory distress and may require immediate medical attention, hence early discharge is not an option.
D: The client with cancer and a sealed implant for radiation therapy may require ongoing monitoring and supportive care, so early discharge may not be advisable.

A. Fever B. Drooling C. Tinnitus D. Steatorrhea

Correct Answer is A

Explanation

A. Fever is a common manifestation of bacterial pneumonia, as it indicates the body's immune response to infection. Other typical symptoms include cough, shortness of breath, chest pain, and sputum production.
B. Drooling is not typically associated with bacterial pneumonia but may occur in conditions such as epiglottitis or aspiration pneumonia.

C. Tinnitus is not a characteristic manifestation of bacterial pneumonia but may occur with other conditions affecting the ear.
D. Steatorrhea refers to fatty stools and is not associated with pneumonia.

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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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