A nurse is providing discharge instruction to the family of a client who has Parkinson's disease and is a fall risk. Which of the following information should the nurse provide?
(Select All that Apply.)

Obtain a hospital bed and keep all four siderails up.

Remove all throw rugs from the home.

Install handrails in the bathroom.

Ensure adequate lighting along walking spaces.

Keep walking areas free of clutter.

Answer and Explanation

Correct Answer : B,C,D,E

Choice A Reason:

Obtaining a hospital bed and keeping all four siderails up, may not be the best choice. While a hospital bed with siderails may be appropriate for some individuals with Parkinson's disease who are at high risk of falls, keeping all four siderails up continuously can potentially restrict mobility and independence. It's important to balance safety with the client's comfort and ability to move independently.

Choice B Reason:

Removing all throw rugs from the home is correct. Throw rugs can be tripping hazards, especially for individuals with mobility issues or balance problems. Removing throw rugs can reduce the risk of trips and falls within the home.

Choice C Reason:

Installing handrails in the bathroom is correct. Installing handrails in the bathroom, especially near the toilet and shower, can provide additional support and stability for individuals with Parkinson's disease when performing daily activities. This can help prevent falls in a potentially slippery environment.

Choice D Reason:

Ensuring adequate lighting along walking spaces is correct. Good lighting is crucial for individuals with Parkinson's disease to see obstacles and hazards clearly. Adequate lighting along walking spaces helps improve visibility and reduces the risk of falls, especially during nighttime or low-light conditions.

Choice E Reason:

Keeping walking areas free of clutter is correct. Clutter and obstacles in walking areas increase the risk of tripping and falling, particularly for individuals with Parkinson's disease who may have difficulty with balance and coordination. Keeping walking areas clear of clutter helps create a safer environment.

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Correct Answer is ["A","B","D"]

Explanation

Choice A Reason:

Pupillary dilation is correct. Pupillary changes can indicate neurological dysfunction following a head injury. Dilated pupils may suggest increased intracranial pressure or damage to specific brain structures.

Choice B Reason:

Persistent headache is correct .Headaches are a common symptom following a head injury. Persistent or worsening headaches can indicate ongoing neurological issues and should be monitored closely.

Choice C Reason:

Presence of hand tremors is incorrect. Hand tremors are not typically associated with loss of consciousness following a motor vehicle accident. While hand tremors can occur in various conditions, such as essential tremor or Parkinson's disease, they are not typically a direct manifestation of a head injury. The primary concern immediately following a motor vehicle accident with loss of consciousness is assessing for signs of neurological dysfunction, such as altered level of consciousness, pupillary changes, and persistent headache. Hand tremors may be assessed in other contexts, but they are not directly related to the immediate assessment of a client following a motor vehicle accident with loss of consciousness.

Choice D Reason:

Difficulty waking is correct. Difficulty waking or altered level of consciousness can indicate neurological impairment and may be indicative of a concussion or other brain injury.

E. Foot drop is incorrect. Foot drop refers to difficulty lifting the front part of the foot, which can cause dragging of the foot or toes along the ground while walking. While foot drop can result from various neurological conditions or injuries, it is not typically associated with loss of consciousness following a motor vehicle accident. Loss of consciousness after a motor vehicle accident is more indicative of potential head trauma or concussion, which may present with symptoms such as altered level of consciousness, headache, pupillary changes, or difficulty waking. Foot drop would be more relevant to assess in contexts related to peripheral nerve injury, spinal cord injury, or neurological conditions affecting the lower extremities. Given the scenario provided, foot drop is not a typical manifestation that the nurse would assess for immediately following a motor vehicle accident with loss of consciousness. Therefore, option E is not relevant in this scenario.

A. Bladder spasms B. Hypotension C. Delayed wound healing D. Hirsutism E. Hyperglycemia

Correct Answer is ["C","D","E"]

Explanation

Choice A Reason:

Bladder spasms are not commonly reported as adverse effects of methylprednisolone. However, bladder dysfunction can occur in individuals with multiple sclerosis due to the disease process itself, but it is not specifically related to corticosteroid therapy.

Choice B Reason:

Hypotension is not a common adverse effect of methylprednisolone. In fact, corticosteroids can often lead to fluid retention and sodium retention, which can contribute to hypertension rather than hypotension.

Choice C Reason:

Delayed wound healing is correct. Corticosteroids can impair the body's ability to heal wounds by suppressing the inflammatory response and collagen synthesis. Therefore, clients receiving methylprednisolone may experience delayed wound healing, which can be problematic, especially in individuals with pre-existing wounds or undergoing surgical procedures.

Choice D Reason:

Hirsutism (excessive hair growth, especially in women) can occur with long-term corticosteroid use due to the effect of steroids on hair follicles. It is a possible adverse effect of methylprednisolone.

Choice E Reason:

Hyperglycemia is correct. Corticosteroids can increase blood glucose levels by promoting gluconeogenesis, reducing glucose uptake by tissues, and inducing insulin resistance. Clients receiving methylprednisolone may develop hyperglycemia, which can be particularly concerning for individuals with diabetes or those at risk of developing diabetes.

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A nurse is providing discharge instruction to the family of a client who has Parkinson's disease and is a fall risk. Which of the following information should the nurse provide? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations should the nurse assess the client for? (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is planning care for a client who has multiple sclerosis and is receiving methylprednisolone. Which of the following adverse effects should the nurse anticipate? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

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A nurse is providing discharge instruction to the family of a client who has Parkinson's disease and is a fall risk. Which of the following information should the nurse provide?
(Select All that Apply.)