# A nurse is assessing a 58-year-old client with amyotrophic lateral sclerosis (ALS). Which assessment finding would be most concerning and require immediate nursing intervention?

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## 문제

A nurse is assessing a 58-year-old client with amyotrophic lateral sclerosis (ALS). Which assessment finding would be most concerning and require immediate nursing intervention?

## 보기

1. Fasciculations observed in the upper extremities
2. Dysphagia with frequent choking episodes during meals **✔ 정답**
3. Muscle atrophy in the hands and forearms
4. Hyperreflexia noted during neurological examination

**정답: 2**

## 해설

Dysphagia with frequent choking poses immediate aspiration risk, leading to pneumonia and respiratory compromise, requiring urgent intervention. Other findings like fasciculations, atrophy, and hyperreflexia are expected in ALS but less urgent.

## 심화 해설

Clinical Reasoning and Prioritization

In amyotrophic lateral sclerosis (ALS), the progressive degeneration of both upper and lower motor neurons leads to a constellation of clinical manifestations. While findings such as fasciculations, muscle atrophy, and hyperreflexia are hallmark signs of the disease process, they do not typically represent an immediate threat to airway integrity or physiological stability. The assessment finding that requires the most urgent intervention is dysphagia with frequent choking episodes during meals.

The rationale for prioritizing this finding is rooted in the shared brainstem circuitry that coordinates oropharyngeal motor functions. In neurodegenerative conditions like ALS, bulbar dysfunction impairs tongue propulsion and motility, directly compromising both the oral and pharyngeal phases of swallowing [3]. When a client exhibits frequent choking, it signals a failure of the laryngeal protective mechanisms, placing them at high risk for aspiration. Aspiration of food particles or secretions can rapidly progress to aspiration pneumonia, a leading cause of mortality in ALS. Furthermore, a compromised swallowing mechanism can lead to acute airway obstruction, which constitutes a medical emergency requiring immediate intervention.

The other options represent expected clinical features of ALS that, while important to document and manage, do not require the same level of immediate, life-saving intervention. Fasciculations (option 1) and muscle atrophy (option 3) are direct consequences of lower motor neuron degeneration and are chronic, non-emergent findings. Hyperreflexia (option 4) results from the loss of inhibitory modulation by upper motor neurons and is a common, non-imminently dangerous sign. In contrast, the inability to protect the airway during oral intake, as evidenced by choking, necessitates an immediate nursing response, such as holding oral intake, suctioning the airway if indicated, and notifying the provider to assess for alternative nutritional and airway management strategies [3].References (research sources)

- [3]Acoustic Vowel Metrics as Correlates of Dysphagia and Dysarthria in Brainstem Neurodegenerative Diseases.Research articleCapobianco S, Bastiani L, Forli F, Fattori B, Stomeo F, Russo M, Barillari MR, Nacci A. (2025) · DOI: 10.3390/audiolres15060152

## 임상 시나리오

ALS Dysphagia & Airway EmergencyImmediate Intervention for Choking Episodes
In ALS, bulbar dysfunction impairs the oral and pharyngeal phases of swallowing. Frequent choking signals failure of laryngeal protective mechanisms, placing the client at extreme risk for aspiration pneumonia and acute airway obstruction.

Prioritize a focused assessment of breath sounds and oxygen saturation. Immediate interventions include stopping the meal, positioning the client upright, and preparing for suctioning if aspiration is suspected. A speech-language pathology consult for a formal swallow evaluation is essential.

CautionDo not dismiss choking as a minor event. Aspiration can lead to rapid respiratory decompensation. While fasciculations, atrophy, and hyperreflexia are expected ALS findings, dysphagia with choking is a life-threatening priority requiring immediate action to protect the airway.

## 핵심 개념

- **Dysphagia** — Difficulty swallowing, which in ALS results from bulbar muscle weakness and increases the risk of aspiration and airway obstruction.
- **Aspiration Pneumonia** — A lung infection caused by inhaling food, liquid, or saliva into the airways; a leading cause of death in ALS due to impaired swallowing.
- **Bulbar Dysfunction** — Impairment of the brainstem motor nuclei controlling speech, chewing, and swallowing, leading to dysarthria and dysphagia in ALS.
- **Fasciculations** — Visible, involuntary muscle twitches caused by spontaneous firing of denervated motor units, a classic lower motor neuron sign in ALS.

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