A nurse is teaching a client who has amyotrophic lateral sclerosis (ALS) about the end stages of the disease process. Which of the following information should the nurse include in the teaching?
"You might wear splints over affected joints while you are sleeping."
"You will be given dexamethasone to treat muscle atrophy."
"You might require a machine to keep your airway open.
"You will receive nutrition through a central venous access device.
The Correct Answer is C
Choice A rationale:
Wearing splints over affected joints while sleeping is a strategy to prevent contractures, which are common in ALS.
Choice B rationale:
Dexamethasone is not used to treat muscle atrophy in ALS.
Choice C rationale:
As ALS progresses, clients may lose the ability to control their respiratory muscles, and a machine such as a ventilator may be required to assist with breathing.
Choice D rationale:
Nutrition through a central venous access device is not a standard intervention for ALS, as the focus is on preserving the client's ability to eat and swallow for as long as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Eliminating unhealthy foods is generally a good practice, but specific guidance related to managing hyperemesis gravidarum is needed.
Choice B rationale:
Dairy products can be included in the diet unless the client has a specific intolerance or allergy.
Choice C rationale:
Drinking water with each meal can be helpful, but avoiding dehydration is more important. Fluid intake should be consistent throughout the day.
Choice D rationale:
Hyperemesis gravidarum is a condition that causes severe nausea and vomiting during pregnancy, which can lead to dehydration, electrolyte imbalance, and weight loss. To prevent or reduce these complications, the nurse should instruct the client to eat foods at colder temperatures, as they are less likely to trigger nausea than hot or spicy foods. The client should also eat small, frequent meals and avoid foods that are greasy, fatty, or have strong odors.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.
Choice B rationale:
Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.
Choice C rationale:
Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.
Choice D rationale:
Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.
Choice E rationale:
Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.
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