Nokea
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?
- A. Increasing anxiety.
- B. Inappropriate laughter.
- C. Asymmetrical weakness.
- D. Weakened cough effort.
Correct Answer: D
Rationale: 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.
You may also like to solve these questions
The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?
- A. Collect the blood sample.
- B. Select another finger.
- C. Apply pressure to the site.
- D. Assess radial pulse volume.
Correct Answer: B
Rationale: Selecting another finger ensures an accurate blood sample and minimizes discomfort, as a reddened and engorged fingertip may lead to inaccurate readings.
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
- A. Auscultate the abdomen for bowel sound activity.
- B. Bring additional sterile dressing supplies to the room.
- C. Obtain a sample of the drainage to send to the laboratory.
- D. Prepare the client to return to the operating room.
Correct Answer: D
Rationale: Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Orient the client to the environment
- B. Call for an ophthalmological exam
- C. Provide an eye patch
- D. Avoid activities that will increase intraocular pressure
- E. Strabismus
- F. Glaucoma
Correct Answer: D
Rationale: The client is most likely experiencing diabetic retinopathy, a complication of poorly controlled type 1 diabetes. Calling for an ophthalmological exam and orienting the client to the environment address the condition, while monitoring blood glucose and visual acuity assess progress.
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?
- A. Palpitations and shortness of breath.
- B. Bradycardia and constipation.
- C. Muscle cramping and dry, flushed skin.
- D. Lethargy and lack of appetite.
Correct Answer: A
Rationale: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine.
The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Have the client sign the surgical and transfusion permits.
- B. Notify the healthcare provider of the client's medication history.
- C. Ensure that the potential for bleeding is explained to the client.
- D. Observe the heparin injections sites for signs of bruising.
Correct Answer: B
Rationale: Notifying the healthcare provider of the client's heparin use is crucial to ensure appropriate perioperative management and prevent excessive bleeding during surgery.