The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

The person's cognitive and mental capacity will most likely remain intact throughout the disease progression.

The person's ability to swallow will remain intact throughout the disease.

The person's risk for seizures increases with progression of the disease.

The person's breathing will not be affected by the disease.

Answer and Explanation

The Correct Answer is A

Choice A reason: ALS is a neurodegenerative disease that affects the motor neurons, which control the voluntary muscles. It does not affect the cognitive or mental functions, such as memory, reasoning, or emotions. Therefore, the person with ALS will be aware of their condition and their surroundings, even when they lose their ability to move, speak, or breathe.

Choice B reason: ALS affects the muscles of the mouth, throat, and chest, which are involved in swallowing. As the disease progresses, the person with ALS will have difficulty swallowing food, liquids, and saliva. This can lead to malnutrition, dehydration, choking, and aspiration pneumonia.

Choice C reason: ALS does not directly cause seizures, which are abnormal electrical activity in the brain. However, some medications used to treat the symptoms of ALS, such as muscle relaxants, may increase the risk of seizures. Therefore, the person with ALS should be monitored for any signs of seizures, such as loss of consciousness, convulsions, or confusion.

Choice D reason: ALS affects the muscles of the diaphragm and the intercostal muscles, which are involved in breathing. As the disease progresses, the person with ALS will have difficulty breathing, especially at night or when lying down. This can lead to respiratory failure, which is the most common cause of death in ALS. Therefore, the person with ALS may need mechanical ventilation or noninvasive positive pressure ventilation to support their breathing.

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Correct Answer is B

Explanation

Choice A reason: Observing the time of onset and end of seizure activity is important, but it is not the priority action. The nurse should first ensure the safety of the client and prevent injury.

Choice B reason: Removing objects within reach of the client's arms and legs is the correct action, as it prevents the client from hitting or injuring themselves during the seizure. The nurse should also lower the bed and raise the side rails.

Choice C reason: Loosening any restrictive clothing around the neck is a good practice, but it is not as urgent as removing objects. The nurse can do this after ensuring the client's safety.

Choice D reason: Placing a padded tongue blade in the client's mouth is a wrong and dangerous action, as it can cause choking, aspiration, or damage to the teeth and oral mucosa. The nurse should never force anything into the client's mouth during a seizure.

A. may be necessary to prevent pulmonary thrombosis. B. is contraindicated because it will cause additional bleeding. C. is inadvisable because it may mask signs and symptoms of neurologic changes in the brain. D. will be started if necessary to enhance cerebral circulation.

Correct Answer is B

Explanation

Choice A reason: This is incorrect. Anticoagulant therapy may be necessary to prevent pulmonary thrombosis in patients with ischemic stroke, which is caused by a blood clot blocking a blood vessel in the brain. However, in patients with hemorrhagic stroke, which is caused by a ruptured blood vessel in the brain, anticoagulant therapy can worsen the bleeding and increase the risk of complications.

Choice B reason: This is correct. Anticoagulant therapy is contraindicated because it will cause additional bleeding in patients with hemorrhagic stroke. Anticoagulants are drugs that prevent blood from clotting or dissolve existing clots. They can increase the size of the hematoma and the pressure on the brain tissue, leading to more damage and disability.

Choice C reason: This is incorrect. Anticoagulant therapy is not inadvisable because it may mask signs and symptoms of neurologic changes in the brain. Anticoagulants do not affect the neurological assessment or the diagnosis of stroke. They can, however, interfere with the treatment and recovery of hemorrhagic stroke.

Choice D reason: This is incorrect. Anticoagulant therapy will not be started if necessary to enhance cerebral circulation in patients with hemorrhagic stroke. Anticoagulants do not improve the blood flow to the brain, but rather prevent or dissolve clots that may obstruct it. In patients with hemorrhagic stroke, the pro

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The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who begins to exhibit seizure activity while in bed. Which of the following actions should the nurse implement to care for the client?

Correct Answer is B

Explanation

A family member of a patient diagnosed with a hemorrhagic stroke asks if the patient can receive anticoagulant therapy to improve their outcome. The nurse explains that anticoagulant therapy for the patient

Correct Answer is B

Explanation

The emergency room nurse notes clear drainage dripping from the nose of a newly admitted patient with a head injury after diving into shallow water. Which initial intervention should the nurse perform?

The nurse is educating the family about anticipated changes during the late stages of amyotrophic lateral sclerosis (ALS) for their father. What teaching point is most important for the nurse to include?

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