Free NCLEX-RN Exam Braindumps (page: 175)

Page 175 of 431

Before completing a nursing diagnosis, the nurse must first:

  1. Write goals and objectives
  2. Perform an assessment
  3. Plan interventions
  4. Perform evaluation

Answer(s): B

Explanation:

(A) Goals and objectives are based on a nursing assessment and diagnosis. (B) Assessment is the first step of nursing process. (C) Interventions are nursing actions to meet goals and objectives. (D) Evaluation process follows nursing interventions.



Before completing a nursing diagnosis, the nurse must first:

  1. Write goals and objectives
  2. Perform an assessment
  3. Plan interventions
  4. Perform evaluation

Answer(s): B

Explanation:

(A) Goals and objectives are based on a nursing assessment and diagnosis. (B) Assessment is the first step of nursing process. (C) Interventions are nursing actions to meet goals and objectives. (D) Evaluation process follows nursing interventions.



A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

  1. Loss of ability to speak and communicate effectively
  2. Aspiration and weight loss
  3. Secondary infection resulting from poor oral hygiene
  4. Drooling

Answer(s): B

Explanation:

(A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.



A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:

  1. Loss of ability to speak and communicate effectively
  2. Aspiration and weight loss
  3. Secondary infection resulting from poor oral hygiene
  4. Drooling

Answer(s): B

Explanation:

(A) Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. (B) Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. (C) A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. (D) Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.



Page 175 of 431



Post your Comments and Discuss NCLEX NCLEX-RN exam with other Community members:

Naveen Ahlam commented on November 29, 2024
Great stuff
Anonymous
upvote

Isadora Guimarães commented on November 10, 2024
Very good to study
UNITED STATES
upvote

Marydee commented on April 02, 2020
Just purchased, will see if it is the real deal. Will give a further update later!
Anonymous
upvote