A nurse is providing teaching to a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following client statements indicates an understanding of the teaching?
"I need to make sure other members of my family get immunized against the disease."
"Since I will stay in the hospital, I should begin the process of selling my home."
"I will need to begin hospice care immediately."
"I would like to talk to someone about creating a living will."
The Correct Answer is D
Choice A rationale:
Other family members or close contacts may consider immunization, but it is not directly related to the client's ALS diagnosis.
Choice B rationale:
Since the client has a new diagnosis of ALS, the immediate focus should not be on selling their home, but rather on understanding and managing the disease.
Choice C rationale:
Requiring hospice care immediately is not a standard recommendation for a client with ALS. The client's disease progression and needs will be assessed to determine the appropriate level of care.
Choice D rationale:
Creating a living will is important for clients with a terminal illness like ALS, as it allows them to express their wishes for medical treatment and care preferences in advance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
Choice B rationale:
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
Choice C rationale:
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
Choice D rationale:
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
Correct Answer is C
Explanation
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
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