A nurse in a long-term care facility is collecting data for an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?
The client reports insomnia.
The client requires additional help to stand.
The client has increased difficulty dressing.
The client has difficulty swallowing.
The Correct Answer is D
A) The client reports insomnia:
Insomnia is a common symptom in Parkinson's disease but may not pose an immediate threat to the client's health or require urgent intervention compared to other symptoms such as difficulty swallowing.
B) The client requires additional help to stand:
While needing assistance to stand is indicative of the progression of Parkinson's disease and may require attention, it is not typically considered a priority over symptoms that directly impact the client's safety and well-being.
C) The client has increased difficulty dressing:
Increased difficulty dressing is a manifestation of Parkinson's disease progression and may impact the client's independence and quality of life. However, it is not as immediately life-threatening as difficulty swallowing.
D) The client has difficulty swallowing:
Difficulty swallowing, or dysphagia, is a serious concern in Parkinson's disease as it can lead to aspiration, malnutrition, dehydration, and respiratory complications such as pneumonia. It poses a significant risk to the client's safety and requires prompt attention to prevent complications. Therefore, it is the priority finding to report at the interprofessional care conference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Tying the restraint to the bed frame: This action is appropriate and ensures that the restraint is anchored securely to the bed frame, preventing the client from removing it independently. Tying the restraint to the bed frame is a standard practice to maintain the client's safety.
B) Applying the restraint over the client's gown: While it's generally preferable to apply restraints directly to the client's skin to minimize movement and ensure effectiveness, applying the restraint over the gown is acceptable in some situations. However, it's essential to ensure that the restraint is snug and properly secured to prevent the client from slipping out of it.
C) Placing the restraint across the client's chest: Placing the restraint across the client's chest is not recommended because it can restrict chest expansion and interfere with breathing, potentially leading to respiratory compromise. Restraints should be applied to minimize movement while allowing the client to breathe comfortably.
D) Using a quick-release knot to secure the restraint: Using a quick-release knot is essential when applying restraints to ensure that they can be quickly removed in case of an emergency or if the client experiences distress. This promotes client safety and allows for rapid intervention if needed.
Correct Answer is B
Explanation
A) Select the appropriate dressing:
Choosing the appropriate dressing is an essential step in the process of changing a wound dressing. However, before selecting a dressing, the nurse should first review the available dressing types to ensure that the choice is based on a comprehensive understanding of the client's wound characteristics, such as size, depth, exudate level, and presence of infection. Jumping straight to selecting a dressing without reviewing available options may result in choosing an inadequate or inappropriate dressing for the client's specific wound care needs.
B) Review available dressing types:
This is the most appropriate initial step in the process of changing a wound dressing. Before proceeding with the dressing change, the nurse should assess the client's wound and review the available dressing types to determine which one is most suitable. Factors to consider include the wound's characteristics, such as size, depth, and exudate level, as well as any specific requirements based on the stage of the pressure ulcer and the client's overall condition. Reviewing available dressing types ensures that the nurse makes an informed decision and selects the most appropriate dressing for promoting wound healing and preventing complications.
C) Document the dressing change:
Documentation is an essential aspect of wound care, as it provides a record of the client's progress, the interventions performed, and the client's response to treatment. While documenting the dressing change is important, it should occur after the dressing change itself. Documenting before completing the dressing change could lead to incomplete or inaccurate documentation, as the nurse may need to record details about the wound's appearance, the type of dressing used, and any observations made during the procedure.
D) Change the dressing:
Changing the dressing is a necessary step in the wound care process, but it should not be the first action taken without assessing the wound and reviewing available dressing options. Proceeding directly to changing the dressing without considering the client's specific wound care needs and available dressing types may result in suboptimal wound management and compromise the client's healing process.
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