To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

Teach the client breathing exercises.

Establish a regular bladder routine.

Perform chest physiotherapy.

Encourage use of incentive spirometer.

Initiate passive range of motion exercises.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A reason: Teaching the client breathing exercises can help improve lung function, reduce mucus accumulation, and prevent atelectasis and pneumonia. Breathing exercises can include pursed-lip breathing, diaphragmatic breathing, and coughing techniques.

Choice B reason: Establishing a regular bladder routine is not directly related to pulmonary complications. However, it can help prevent urinary tract infections, bladder distension, and incontinence, which are common problems for clients with ALS.

Choice C reason: Performing chest physiotherapy can help mobilize secretions, improve ventilation, and prevent respiratory infections. Chest physiotherapy can include percussion, vibration, and postural drainage.

Choice D reason: Encouraging use of incentive spirometer can help increase lung expansion, improve oxygenation, and prevent alveolar collapse. Incentive spirometer is a device that measures the amount of air the client can inhale and exhale.

Choice E reason: Initiating passive range of motion exercises can help maintain joint mobility, prevent contractures, and improve circulation. Passive range of motion exercises are performed by the nurse or a caregiver who moves the client's limbs through their full range of motion.

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Correct Answer is C

Explanation

Choice A reason: Teaching the client relaxation techniques is a helpful action that the nurse can implement, but it is not the most important one. Relaxation techniques, such as deep breathing, meditation, or guided imagery, can help the client cope with stress, anxiety, and agitation, which are common symptoms of Grave’s disease, a condition that causes hyperthyroidism and overactivity of the thyroid gland. However, relaxation techniques alone cannot address the client’s physical needs, such as hydration, nutrition, and electrolyte balance, which are more urgent and critical.

Choice B reason: Determining the client’s food preferences is a considerate action that the nurse can implement, but it is not the most important one. Food preferences, such as taste, texture, temperature, and variety, can affect the client’s appetite and willingness to eat, which are important factors for maintaining adequate nutrition and weight. However, food preferences may not be the main reason for the client’s refusal to eat, and they may not be enough to overcome the client’s metabolic demands, which are increased by Grave’s disease.

Choice C reason: Maintaining a patent intravenous site is the most important action that the nurse should implement, given the client’s situation. A patent intravenous site can allow the nurse to administer fluids, electrolytes, medications, and nutrients to the client, who is at risk of dehydration, malnutrition, and complications from Grave’s disease, such as thyroid storm, cardiac arrhythmias, and infection. The nurse should monitor the client’s vital signs, fluid intake and output, blood glucose, and thyroid function tests, and adjust the intravenous therapy accordingly.

Choice D reason: Keeping room temperature cool is a supportive action that the nurse can implement, but it is not the most important one. Room temperature can affect the client’s comfort and thermoregulation, which are impaired by Grave’s disease, which causes heat intolerance, sweating, and fever. However, room temperature alone cannot correct the underlying hormonal imbalance or the systemic effects of Grave’s disease, and it may not be sufficient to prevent the client from becoming restless and agitated.

A. Explain specific reason for urgent notification. B. Obtain a PRN prescription for acetaminophen for fever over 101° F (38.3° C). C. Preface the report by stating the client’s name and admitting diagnosis. D. Communicate the pre-transfusion temperatures.

Correct Answer is C

Explanation

Choice A reason: Explaining the specific reason for urgent notification is important, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice B reason: Obtaining a PRN prescription for acetaminophen for fever over 101° F (38.3° C) is a possible recommendation that the nurse can make, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

Choice C reason: Prefacing the report by stating the client’s name and admitting diagnosis is the first information that the nurse should provide, according to the SBAR communication process. This helps to establish the identity and context of the client and the situation.

Choice D reason: Communicating the pre-transfusion temperatures is part of the assessment that the nurse should provide, but it is not the first information that the nurse should provide. The nurse should first identify the client and the situation, then provide the background, assessment, and recommendation.

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To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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