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 C
Explanation
Choice A rationale:
Decreased muscle mass can be a normal age-related change in older adults and is not necessarily indicative of elder maltreatment.
Choice B rationale:
White circles surrounding the cornea (arcus senilis) is a common age- related finding and is not necessarily indicative of elder maltreatment.
Choice C rationale:
The presence of urine odor on the client's clothes could indicate neglect or inadequate care and should be further investigated.
Choice D rationale:
Nodules on the metacarpal joints may be related to osteoarthritis, which is a common condition in older adults and may not necessarily indicate elder maltreatment.
Correct Answer is A
Explanation
Choice A rationale:
Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.
Choice B rationale:
A fetal heart rate of 120/min is within a normal range and is not concerning.
Choice C rationale:
Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.
Choice D rationale:
Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.
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