Exam NCLEX-RN topic 4 question 222 discussion

Actual exam question from Test Prep's NCLEX-RN

Question #: 222
Topic #: 4

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:

A. Loss of ability to speak and communicate effectively
B. Aspiration and weight loss
C. Secondary infection resulting from poor oral hygiene
D. Drooling

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Suggested Answer: B 🗳️
(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 clients 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.

by irae1983 at March 16, 2021, 5:55 a.m.

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irae1983

4 months, 3 weeks ago

It is not the dysphasia it is dysphagia!

upvoted 2 times

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Exam NCLEX-RN topic 4 question 222 discussion

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irae1983

SY0-701