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. Sipping fluids with each meal may help prevent dehydration and promote hydration but is not the most important dietary instruction post-gastric bypass surgery.

B. Chewing slowly and thoroughly is important for digestion but is not specific to post-gastric bypass dietary needs.

C. Reducing intake of fatty foods is important for overall health but is not the most critical dietary instruction post-gastric bypass surgery.

D. Eating small frequent meals is crucial after gastric bypass surgery to prevent complications such as dumping syndrome, promote adequate nutrient absorption, and manage portion sizes effectively.

A. Avoid wearing tight fitting clothes. B. Minimize intake of spicy foods. C. Begin a smoking cessation program. D. Remain upright following meals.

Correct Answer is D

Explanation

A. Avoiding tight-fitting clothes can help reduce intra-abdominal pressure, which may contribute to GERD symptoms, but it is not the most crucial instruction.

B. Minimizing intake of spicy foods can help decrease gastric irritation and reflux symptoms, but it is not the most important instruction.

C. Beginning a smoking cessation program is important for overall health and may help reduce GERD symptoms, but it is not the most critical instruction for managing GERD.

D. Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter. This instruction helps minimize reflux episodes and should be emphasized to the client with GERD.

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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

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

Correct Answer is D

Explanation

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Correct Answer is D

Explanation

The nurse is caring for a client that is unconscious and having seizures. Which nursing intervention is most essential in this client's plan of care (POC)

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A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

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