While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Increasing anxiety.

Inappropriate laughter.

Asymmetrical weakness.

Weakened cough effort.

Answer and Explanation

The Correct Answer is D

A. Increasing anxiety may require intervention, but it does not pose an immediate threat to the client's health compared to other options.

B. Inappropriate laughter could indicate emotional lability, a common symptom in ALS, but it does not typically require immediate intervention unless it's accompanied by other concerning symptoms.

C. Asymmetrical weakness is common in ALS but may not necessarily warrant immediate intervention unless it is significantly affecting the client's ability to perform essential functions.

D. Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.

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Correct Answer is D

Explanation

A. Muscle atrophy may indicate various underlying conditions but is not typically associated with an exacerbation of SLE. While it should be noted, it is not the most critical finding to report in this context.

B. Low-grade fever is a common symptom of SLE exacerbation and may not require immediate reporting unless accompanied by other concerning symptoms.

C. Joint pain is a hallmark symptom of SLE exacerbation but may not warrant immediate reporting unless it is severe or debilitating.

D. Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.

Correct Answer is ["0.4"]

Explanation

To determine the correct dosage, the nurse needs to perform a calculation using the information provided. The prescription is for 200,000 units of penicillin, and the available vial concentration is 500,000 units per mL.

To find out how many mLs to administer, the nurse would divide the prescribed units by the concentration of units per mL. This is calculated as 200,000 units divided by 500,000 units/mL, which equals 0.4 mL.

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While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

Correct Answer is D

Explanation

The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL. How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.4"]

Explanation

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While caring for a client with amyotrophic lateral sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?

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