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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Positioning the client over an overbed table is not appropriate for a paracentesis procedure and may interfere with the procedure.
B. Emptying the bladder before the procedure helps to reduce the risk of accidental bladder puncture during paracentesis.
C. Administering IV fluids prior to the procedure is not typically indicated for a paracentesis, unless specifically ordered by the provider for hydration purposes.
D. NPO status is not typically required before a paracentesis procedure unless otherwise specified by the provider.
Correct Answer is A
Explanation
A. Uneven shoulder and pelvic heights are classic signs of scoliosis, visible during a physical examination where one shoulder or hip may appear higher than the other.
B. Mild pain in the hip region is not a specific indicator of scoliosis.
C. Exaggerated curvature of the sacrum is not a specific indicator of scoliosis.
D. Limited range-of-motion of the hips is not a specific indicator of scoliosis
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