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 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.
Correct Answer is []
Explanation
Based on the provided nurses' notes, the client exhibits symptoms that may suggest a brief psychotic disorder, characterized by delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior. The client's history of similar episodes and family history could support this diagnosis. To assess the client's progress, the nurse should monitor the client's ability to care for themselves and assess any suicide risk due to the client's recent stressors and emotional state. Actions that could be beneficial include reducing external stimuli to prevent sensory overload and engaging with the client several times each day to establish trust, which can help alleviate anxiety and foster a therapeutic environment.
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