A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?
Fall precautions.
Aspiration precautions.
Reorientation cues.
Bowel training.
The Correct Answer is A
A. Implementing fall precautions is the most important intervention for a client with Parkinson’s disease experiencing decreased postural reflexes, rigidity, and gait issues. These symptoms significantly increase the risk of falls, so fall precautions are crucial for preventing injury.
B. Aspiration precautions are important for many clients, but they are less immediately relevant in this context compared to fall prevention. The symptoms listed do not directly indicate a high risk of aspiration.
C. Reorientation cues may be necessary for clients with cognitive issues but are not the primary concern for managing motor symptoms like those listed. The focus here should be on physical safety rather than cognitive orientation.
D. Bowel training is a useful intervention for managing bowel function but is not directly related to the acute risks of fall and gait disturbances associated with Parkinson’s disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hoarseness in the voice following a thyroidectomy can be a sign of vocal cord damage or laryngeal nerve injury, which are potentially serious complications. The appropriate action is to notify the unit charge nurse to escalate the finding for further assessment by a physician or advanced practice provider.
B. Administering humidified oxygen does not specifically address the issue of hoarseness. While humidified oxygen might be beneficial for general respiratory comfort, it is not a targeted intervention for potential vocal cord damage.
C. Ensuring that the drainage device is compressed is important for managing surgical wounds but does not address or diagnose vocal cord issues. Hoarseness after thyroid surgery is more indicative of a potential complication rather than a drainage issue.
D. Obtaining ice chips does not address the underlying cause of the hoarseness and may not provide significant relief. The priority is to identify potential complications rather than offering symptomatic relief.
Correct Answer is A
Explanation
A. Lifting the skin is a common technique used to assess skin turgor, which is the elasticity of the skin.By letting go, the nurse can observe how quickly the skin snaps back into place, indicating good or poor elasticity.
B. recording palpated temperature might be done during a focused assessment, but it wouldn't necessarily be the next step after lifting the skin.
C. measuring indentation depth might be relevant for assessing edema (swelling), but it's not the primary focus after lifting for turgor.
D. observing swelling could be assessed visually without lifting the skin, and while it's important, assessing elasticity comes first in this scenario.
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