Difficulty: Medium
Average Score: 64%
Simulated
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?
Correct answer
C
Rationale
Weakened cough effort in ALS indicates respiratory muscle weakness, increasing the risk of aspiration and respiratory failure, requiring immediate intervention.