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?

Inappropriate laughter.

Asymmetrical weakness.

Increasing anxiety.

Weakened cough effort.

Answer and Explanation

The Correct Answer is D

Weakened cough effort can lead to ineffective airway clearance and increase the risk of aspiration pneumonia, a common complication in ALS due to bulbar muscle involvement. Aspiration pneumonia is a serious and potentially life-threatening condition that requires immediate intervention
A This symptom can be distressing for the client and may impact their quality of life. While it should be addressed and managed, it does not pose an immediate threat to the client's physical health.
B Asymmetrical weakness is a hallmark feature of ALS, where muscle weakness typically begins in one region of the body and gradually spreads to other areas. While it signifies disease progression and may impact the client's mobility and function, it does not necessarily require immediate intervention.
C Anxiety is a common emotional response in clients with ALS, especially as the disease progresses and the client faces physical decline and uncertainty about the future. While it is important to address the client's emotional well-being and provide support, increasing anxiety does not usually warrant immediate intervention.

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Correct Answer is A

Explanation

A. Remaining upright following meals helps prevent gastric contents from refluxing into the esophagus by promoting gravity-assisted emptying of the stomach and reducing intra- abdominal pressure. This can help alleviate symptoms of GERD such as heartburn and regurgitation.
B. Wearing tight fitting clothes can contribute to increased pressure on the abdomen, which may worsen symptoms of GERD by further compressing the stomach and promoting reflux. While avoiding tight fitting clothes is important for minimizing discomfort, it is not as critical as remaining upright following meals in managing GERD symptoms.
C. Spicy foods can exacerbate symptoms of GERD in some individuals by irritating the esophagus and increasing gastric acid secretion. While minimizing intake of spicy foods is advisable for many people with GERD, it may not be as universally important as the instruction to remain upright following meals.
D. Quitting smoking is important for overall health and can help improve symptoms of GERD. However, while smoking cessation is beneficial, it may not directly address the immediate need to minimize symptoms following meals as the instruction to remain upright does.

A. Wear prescription glasses. B. Eat a diet high in carotene. C. Maintain prescribed eye drop regimen. D. Avoid frequent eye pressure measurements.

Correct Answer is C

Explanation

C. In glaucoma management, the use of topical eye drops to reduce intraocular pressure is a cornerstone of treatment. These medications work to decrease fluid production in the eye or increase fluid drainage, thereby lowering IOP and reducing the risk of optic nerve damage and vision loss. Adherence to the prescribed eye drop regimen is crucial for controlling IOP and preventing further vision deterioration.
A. While wearing prescription glasses may be important for correcting vision problems, such as nearsightedness or farsightedness, they do not directly address the underlying issue of increased intraocular pressure associated with glaucoma.
B. While maintaining a healthy diet rich in nutrients, including carotene, is important for overall eye health, there is no evidence to suggest that it directly affects the progression of glaucoma or intraocular pressure.
D. Regular monitoring of intraocular pressure is an essential part of managing glaucoma. Frequent eye pressure measurements help assess the effectiveness of treatment and detect any changes in intraocular pressure that may indicate progression of the disease.

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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

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 A

Explanation

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Correct Answer is C

Explanation

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