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

Weakened cough effort

Asymmetrical weakness

Answer and Explanation

The Correct Answer is C

A. Increasing anxiety:
While emotional and psychological aspects are important in holistic care, immediate intervention is usually required for physiological concerns. Increasing anxiety may need attention, but it is not as urgent as addressing potential respiratory issues.

B. Inappropriate laughter:
Changes in emotional expression, such as inappropriate laughter, can occur in ALS due to involvement of upper motor neurons. While notable, it may not be as urgent as addressing respiratory concerns.

C. Weakened cough effort.
In ALS, respiratory muscles can become affected as the disease progresses, leading to respiratory complications. Weakened cough effort is concerning because it can indicate potential respiratory muscle weakness, which may lead to difficulty clearing secretions and an increased risk of respiratory compromise or infection.

D. Asymmetrical weakness:
Asymmetrical weakness is a common feature of ALS, but it may not necessarily warrant immediate intervention unless there are sudden changes or signs of acute distress. Respiratory symptoms, such as weakened cough effort, often require more immediate attention.

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Correct Answer is D

Explanation

A. Guidelines for oxygen use:
While guidelines for oxygen use are important, addressing the root cause of the respiratory condition, which includes smoking cessation, is crucial for long-term management.

B. Methods for weight loss:
Obesity can contribute to respiratory issues, but in the immediate context of emphysema exacerbation and the need for oxygen therapy, smoking cessation is a more urgent concern.

C. Approaches to conserve energy:
Conserving energy is important for clients with emphysema, but addressing the impact of smoking on respiratory function is a more immediate priority.

D. Strategies for smoking cessation.
Smoking is a major contributor to the progression of emphysema and exacerbation of respiratory symptoms. Addressing smoking cessation is crucial in improving the client's respiratory function and overall health. Continuing to smoke can exacerbate emphysema and compromise the effectiveness of other interventions, including oxygen therapy.

A. Hyperactive bowel sounds. B. Anxiety and sighing. C. Dark yellow urine. D. Myalgia in wrists and hands.

Correct Answer is C

Explanation

A. Hyperactive bowel sounds.
Hyperactive bowel sounds are more suggestive of gastrointestinal issues, such as intestinal hypermotility or increased peristalsis. While diabetes can affect the gastrointestinal system, hyperactive bowel sounds are not a specific indicator of the symptoms described by the client.

B. Anxiety and sighing.
Anxiety and sighing are more indicative of emotional or psychological factors rather than dehydration. While stress can impact blood sugar levels in individuals with diabetes, anxiety and sighing are not direct signs of the dehydration that may be associated with the reported symptoms.

C. Dark yellow urine.
Dark yellow urine can be a sign of concentrated urine, suggesting dehydration. In diabetes, especially when blood sugar levels are elevated, increased urine production (polyuria) can lead to dehydration. Dark yellow urine may indicate that the urine is more concentrated due to a lack of fluid intake.

D. Myalgia in wrists and hands.
Myalgia in the wrists and hands is not a typical symptom of dehydration related to diabetes. It could be associated with various conditions, such as musculoskeletal issues or nerve-related problems. This symptom is less likely to be directly linked to the reported weakness and palpitations.

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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

Correct Answer is D

Explanation

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication?

Correct Answer is C

Explanation

The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide?

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