# A nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who is experiencing spasticity and muscle cramps affecting mobility. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541221 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with amyotrophic lateral sclerosis (ALS) who is experiencing spasticity and muscle cramps affecting mobility. ## 보기 1. Assess swallowing ability and implement aspiration precautions **✔ 정답** 2. Encourage active range of motion exercises to maintain muscle strength 3. Provide emotional support and counseling for depression 4. Administer prescribed muscle relaxants to reduce spasticity **정답: 1** ## 해설 Assessing swallowing and implementing aspiration precautions is the highest priority to prevent aspiration pneumonia, a leading cause of death in ALS patients. Other interventions are important but do not address the immediate life-threatening risk. ## 심화 해설 Understanding the Priority: Airway and Swallowing in ALS When caring for a client with amyotrophic lateral sclerosis (ALS) who is experiencing spasticity and muscle cramps, it is essential to recognize that ALS is a progressive neurodegenerative disease affecting both upper and lower motor neurons. While spasticity and cramps are distressing and impact mobility, the disease process also involves the bulbar muscles—those controlling speech, chewing, and swallowing. The nurse's immediate priority must be to address the most life-threatening complication. In ALS, respiratory failure and aspiration pneumonia are the leading causes of death. Therefore, assessing swallowing ability and implementing aspiration precautions is the critical first step to ensure airway safety. Why Option 1 is the Priority: The Bulbar Connection The spasticity a client experiences in their limbs can also affect the tongue and pharyngeal muscles. Research highlights that bulbar dysfunction is a core feature of ALS that directly compromises swallowing safety . A study using ultrasonography to measure tongue thickness found a direct association between structural changes in the tongue and swallowing dysfunction in ALS patients, underscoring the importance of objective and clinical assessment of the bulbar region . Before addressing mobility or comfort, the nurse must first ensure the client can protect their own airway. Silent aspiration is a significant risk, and a swallowing assessment is the gateway to determining the need for modified diets, thickened liquids, or alternative feeding methods to prevent aspiration pneumonia. Analyzing the Other Options in the Context of ALS Care - Option 2: Encourage active range of motion exercises to maintain muscle strength. While maintaining function is a goal, active exercises against resistance can be detrimental in ALS. Overexertion can lead to muscle fatigue and further breakdown of the motor units, potentially worsening weakness. The priority in the presence of new or worsening bulbar symptoms is airway protection, not strength maintenance. - Option 3: Provide emotional support and counseling for depression. Addressing the psychological impact of a progressive disease like ALS is a vital nursing intervention. However, it is a psychosocial need, which, according to the NCLEX-RN prioritization framework (Maslow's hierarchy), is secondary to a physiological risk like airway compromise. The nurse would address this after stabilizing the immediate physical threat. - Option 4: Administer prescribed muscle relaxants to reduce spasticity. Administering medication to manage spasticity is a valid comfort and mobility intervention. However, many muscle relaxants have central nervous system depressant effects that could further compromise a weak respiratory system or a compromised swallowing mechanism. A thorough assessment, particularly of the bulbar and respiratory function, must precede the administration of such medications to avoid causing harm, such as increased aspiration risk due to sedation. Clinical Integration: A Multi-Domain Assessment The progressive nature of ALS requires a comprehensive, multi-domain assessment approach. While the immediate priority is bulbar function and airway safety, the nurse must also anticipate the trajectory of the disease. Spasticity and cramps, as mentioned in the scenario, affect dexterity and mobility, which are critical for tasks like driving and self-care . The nurse's role is to continuously assess and re-prioritize care. For instance, if the swallowing assessment reveals significant dysfunction, the plan of care shifts to include not only aspiration precautions but also a discussion about nutritional support and advanced care planning. The use of objective tools, such as surface electromyography (sEMG) for bulbar assessment, is an emerging method to provide measurement-based care, moving beyond subjective observation to quantify the degree of impairment . This data-driven approach helps the healthcare team tailor interventions precisely to the client's stage of disease. The immediate clinical judgment, however, starts at the bedside with a focused swallowing assessment to prevent an acute, life-threatening event. ## 임상 시나리오 ALS Nursing Priority: Airway FirstSpasticity signals potential bulbar involvement In amyotrophic lateral sclerosis (ALS), limb spasticity often coexists with bulbar muscle dysfunction. The nurse's immediate priority is to assess swallowing ability because aspiration pneumonia is a leading cause of death. Implement aspiration precautions before addressing mobility or comfort. A bedside swallowing assessment includes checking for dysarthria, absent gag reflex, and drooling. Observe the patient drinking water for coughing or voice changes, which indicate silent aspiration risk. Keep suction equipment ready and position the patient upright at 90 degrees for all oral intake. CautionDo not prioritize active ROM exercises for spastic limbs; this can increase tone and does not protect the airway. Muscle relaxants are secondary interventions that follow airway stabilization. ## 핵심 개념 - **Amyotrophic Lateral Sclerosis (ALS)** — A progressive neurodegenerative disease affecting upper and lower motor neurons, leading to muscle weakness, spasticity, and eventual respiratory failure. - **Bulbar Palsy** — Impairment of the lower cranial nerves (IX-XII) causing dysfunction in speech, chewing, and swallowing, commonly seen in advanced ALS. - **Aspiration Pneumonia** — A life-threatening lung infection caused by inhaling food, saliva, or gastric contents into the airways, a leading cause of death in ALS. - **Spasticity** — A velocity-dependent increase in muscle tone with exaggerated tendon jerks, resulting from upper motor neuron lesions. - **Silent Aspiration** — The entry of material into the airway below the vocal cords without any overt clinical signs such as coughing, common in neurological disorders. ## 같은 주제 문제 - [A 65-year-old male client with amyotrophic lateral sclerosis (ALS) is being assessed by th…](https://mymerci.kr/pages/nclex_q.php?qn_id=541217) - [A nurse is assessing a 58-year-old client with amyotrophic lateral sclerosis (ALS). 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