The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity.
Which action should the nurse include?

Instill 3 mL of normal saline before suctioning.

Instruct the client to cough as the suction tip is removed.

Apply a water-soluble lubricant to the catheter.

Wear protective goggles while performing the procedure.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.

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Correct Answer is A

Explanation

Choice A rationale:

Impaired physical mobility relative to muscle rigidity has the highest priority in the nursing care plan for a client diagnosed with Parkinson's disease. Parkinson's disease is characterized by motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Impaired physical mobility can significantly impact a patient's ability to perform activities of daily living and maintain independence. Addressing this issue is crucial to enhance the patient's quality of life and prevent complications such as falls.

Choice B rationale:

While the risk for aspiration relative to muscle weakness is a valid concern in Parkinson's disease, impaired physical mobility takes precedence as it directly affects the patient's ability to move, ambulate, and perform daily activities. Addressing mobility issues is fundamental to maintaining overall functioning and independence.

Choice C rationale:

The risk for constipation relative to immobility is important to address, but it is not the highest priority. Impaired physical mobility can lead to multiple complications, including constipation. However, improving mobility should be the primary focus to prevent a wide range of issues associated with Parkinson's disease.

Choice D rationale:

Self-care deficit relative to motor disturbance is a concern in Parkinson's disease, but it is not the highest priority. Impaired physical mobility directly impacts a patient's ability to engage in self-care activities. By addressing mobility issues first, the nurse can facilitate the patient's ability to perform self-care tasks more independently in the long run.

A. Sinus tachycardia. B. Menstrual cramps. C. Hypertension. D. Amenorrhea. E. Amenorrhea.

Correct Answer is D

Explanation

Choice A rationale:

Sinus tachycardia may occur in response to various stressors or physiological conditions but is not directly related to anorexia nervosa or severe malnutrition. It is not the primary pathological process resulting from this condition.

Choice B rationale:

Menstrual cramps are not a pathological process but rather a symptom that may result from hormonal changes or other factors. While amenorrhea (absence of menstrual periods) is a common feature of anorexia nervosa, menstrual cramps are not a primary concern in this context.

Choice C rationale:

Hypertension is not typically associated with anorexia nervosa or severe malnutrition. In fact, individuals with anorexia nervosa often experience hypotension (low blood pressure) due to dehydration and nutritional deficiencies.

Choice D rationale:

Amenorrhea is the primary pathological process resulting from the adolescent's consistent maladaptive behavior of anorexia nervosa. Severe malnutrition and low body weight can disrupt the normal menstrual cycle and lead to amenorrhea. This is a significant concern for individuals with anorexia nervosa and can have long-term health implications.

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The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

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Correct Answer is D

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The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity.
Which action should the nurse include?