The nurse is caring for a patient diagnosed with amyotrophic lateral sclerosis. The nurse should assess for which priority problem?
a. Fatigue
b. Bradypnea
c. Hypertension
d. Fall risk
ANS: B
Amyotrophic lateral sclerosis is a chronic condition that causes fatigue; however specific respiratory muscle fatigue leading to braypnea is the priority safety risk. Respiratory muscle fatigue can lead to bradypnea, decreased ventilation, and eventually cessation of breathing which is the condition of highest importance with this illness. Hypertension is not a high priority problem specifically related to ALS. While the patient is a fall risk due to overall skeletal muscle fatigue, respiratory depression is the priority safety risk.
You might also like to view...
Which of the following groups of persons is most likely to be able to access health care?
a. Adults who work in large corporations b. Many employed women c. Older women on fixed incomes d. Young adults, aged 16 to 24 years
Which statements describe stages of therapeutic touch?
1. Centering oneself physically and psychologically to prepare for the healing session. 2. Preparing the field of energy for therapeutic touch through mind sensitizing to detect subtle energy flow changes. 3. Helping the client to "re-pattern" his or her energy through the use of their excess energy. 4. Utilizing herbal remedies to reach the inner power of one's self. 5. Guiding the patient to empty the mind and focus on a pleasant experience.
Expected normal percussion tones include:
a. dullness over the lungs. b. hyperresonance over the lungs. c. tympany over an empty stomach. d. flatness over an empty stomach.
An elderly patient with dementia paces the hallway and often wanders. The nurse documents that the patient is exhibiting which type of behavior characteristic of dementia?
a. Passive behavior b. Functionally impaired behavior c. Involuntary psychomotor behavior d. Nonaggressive psychomotor behavior