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A 71-year-old male client with moderate to late-stage Parkinson disease is admitted from home to the hospital with new-onset orthostatic hypotension and occasional dysphagia. According to his wife, he needs assistance with ADLs only on days when his rigidity is worse, and walks short distances in the house using a walker. Which of the following actions would the nurse take? Select all that apply.

Consult with the speech-language pathologist for a swallowing evaluation.

Place the client on the hospital's fall precautions protocol.

Obtain a prescription for a different antihypertensive medication.

Remind the nursing staff to place the client in a sitting position during meals.

Refer the client for physical and occupational therapy evaluations.

Place the client on a liquid diet to prevent choking.

Perform orthostatic blood pressure checks.

Answer and Explanation

Correct Answer : A,B,E,G

Choice A reason: Consulting with the speech-language pathologist for a swallowing evaluation is essential because the client has occasional dysphagia. Swallowing difficulties can lead to aspiration and other complications, and a proper evaluation can help determine the safest diet and interventions.
Choice B reason: Placing the client on the hospital's fall precautions protocol is crucial due to the client's orthostatic hypotension and use of a walker. These factors increase the risk of falls, and implementing fall precautions can help prevent injuries.
Choice C reason: Obtaining a prescription for a different antihypertensive medication is not indicated in this scenario. There is no information provided that suggests the current medication is inappropriate or ineffective. The focus should be on managing the client's orthostatic hypotension with non-pharmacological interventions.
Choice D reason: Reminding the nursing staff to place the client in a sitting position during meals is important to reduce the risk of aspiration due to dysphagia. Sitting upright can help ensure that food and liquids are swallowed safely.
Choice E reason: Referring the client for physical and occupational therapy evaluations is necessary to address the client's functional mobility and ability to perform ADLs. These therapies can help optimize the client's independence and safety.
Choice F reason: Placing the client on a liquid diet to prevent choking is not appropriate without a swallowing evaluation. The speech-language pathologist should determine the safest diet based on the client's specific needs and swallowing abilities.
Choice G reason: Performing orthostatic blood pressure checks is important for monitoring and managing the client's orthostatic hypotension. Regular checks can help identify changes in blood pressure and guide interventions to prevent falls and related complications.

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Correct Answer is B

Explanation

Choice A reason: Quad coughing is a technique used to help patients with spinal cord injuries improve their coughing ability, but it does not directly prevent autonomic dysreflexia. While it is beneficial for respiratory health, it is not the primary intervention for preventing autonomic dysreflexia.
Choice B reason: Assisting to plan a prescribed bowel program is crucial in preventing autonomic dysreflexia. Bowel impaction is a common trigger for autonomic dysreflexia, and a regular bowel program helps to prevent constipation and ensure regular bowel movements, reducing the risk of this complication.
Choice C reason: Supporting the selection of a high-protein diet is important for overall health and nutrition, but it does not directly prevent autonomic dysreflexia. While proper nutrition is essential for patients with spinal cord injuries, it is not the primary intervention for preventing autonomic dysreflexia.

A. Take a daily multivitamin with iron. B. Restrict fluids to 2 liters per day. C. Limit exposure to crowds. D. Do not drink any caffeinated beverages.

Correct Answer is C

Explanation

Choice A reason: Taking a daily multivitamin with iron is important for overall health, but it is not specifically related to preventing sickle cell crises. While maintaining proper nutrition is essential, it does not directly address the triggers or management of sickle cell crises.
Choice B reason: Restricting fluids to 2 liters per day is not appropriate for patients with sickle cell disease. In fact, maintaining adequate hydration is crucial to prevent sickling of red blood cells and reduce the risk of a sickle cell crisis. Restricting fluids could lead to dehydration, which can exacerbate the condition.
Choice C reason: Limiting exposure to crowds is an important instruction for patients with sickle cell disease. Crowded environments can increase the risk of infections, which can trigger a sickle cell crisis. By avoiding crowded places, patients can reduce their exposure to potential infections and help prevent crises.
Choice D reason: While avoiding caffeinated beverages is generally good advice for overall health, it is not specifically related to preventing sickle cell crises. Caffeine can cause dehydration, but the primary focus for preventing crises is maintaining proper hydration and avoiding infections.

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