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.
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Related Questions
Correct Answer is D
Explanation
A. Adding medication directly to enteral feeding can cause clogging of the tube and interfere with medication absorption.
B. Flushing with only 5 mL of water is insufficient. Typically, the tube should be flushed with 15-30 mL of water before and after administering each medication to ensure the tube is clear and to prevent clogging.
C. Dissolving medications together may lead to drug interactions or alterations in drug absorption and should be avoided.
D. Using a syringe to allow the medications to flow by gravity ensures that the medications are delivered safely and steadily. After each medication is administered, the tube should be flushed with water to ensure it is clear and to prevent interactions between different medications.
Correct Answer is []
Explanation
Potential condition:
The client's admission assessment reveals symptoms consistent with SLE, such as fever, joint discomfort, malaise, macular rash on the cheeks, and generalized pain.
The laboratory results show an elevated erythrocyte sedimentation rate (ESR), which is a common finding in SLE.
Action to take:
In managing this condition, the nurse should ensure that the client has an intake of at least 200 mL/hr to maintain adequate hydration, which is crucial for patients with SLE to help prevent kidney damage from inflammation. Additionally, the nurse should encourage the client to avoid direct sunlight, as UV rays can exacerbate SLE symptoms.
Parameters to monitor:
To monitor the client's progress, the nurse should regularly check the erythrocyte sedimentation rate to assess the level of inflammation. Vital signs should also be monitored every 4 hours to ensure stability and detect any changes that may require medical intervention.
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