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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Facial puffiness and periorbital edema:
These are common signs of hypothyroidism but may not require immediate action unless accompanied by severe symptoms.
B. Cold and dry skin:
Cold and dry skin is a characteristic feature of hypothyroidism, but a further decline in the level of consciousness is a more urgent issue.
C. Further decline in the level of consciousness.
A decline in the level of consciousness is a critical sign that requires immediate attention, as it may indicate worsening hypothyroidism, myxedema coma, or other serious complications. Myxedema coma is a life-threatening condition associated with severe hypothyroidism, and it requires prompt medical intervention.
D. Hematocrit of 30% (0.30):
While anemia is a potential complication of hypothyroidism, a hematocrit of 30% alone may not be the most immediate concern compared to a decline in the level of consciousness.
Correct Answer is B
Explanation
A. Keep the room at a comfortable temperature:
While maintaining a comfortable room temperature is important for the overall well-being of the client, it is not the most essential intervention during a seizure. The priority during a seizure is to ensure the client's safety, particularly focusing on airway management.
B. Ensure oral suction is available:
This is the most essential intervention. During a seizure, the client may produce excessive saliva, and having oral suction readily available helps prevent airway obstruction and ensures a clear airway. It is crucial for the safety and well-being of the client.
C. Provide frequent mouth care:
Mouth care is important for the overall hygiene of the unconscious client, but it may not be the most immediate priority during a seizure. The focus during a seizure is on preventing complications such as aspiration or airway obstruction.
D. Maintain the client in a semi-Fowler's position:
Positioning is important for the comfort and safety of the unconscious client, but maintaining a semi-Fowler's position may not be the primary concern during an active seizure. The immediate focus is on airway management and preventing injury.
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