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, F, E
Explanation
A. Take the child's pulse
Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.
F. Determine if the child's airway is clear
Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.
D. Start a peripheral IV line
Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.
E. Look for any open wounds
Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.
Correct Answer is A
Explanation
A. Understanding what the voices are saying is the most important initial step in assessing auditory hallucinations. This information helps the PN gauge the content of the hallucinations, which is crucial for developing a treatment plan and determining the level of risk to the client or others.
B. While knowing when the voices are most disturbing provides useful information for managing symptoms, it is less critical than understanding the content of the hallucinations for developing an initial treatment plan.
C. Assessing how the client copes with the voices is important for ongoing management but comes after understanding what the voices are saying. Coping strategies can be developed based on the nature of the hallucinations.
D. Determining which medication works best is not an immediate priority during the initial assessment. Medication effectiveness will be evaluated over time rather than being a primary focus during the first report of hallucinations.
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