In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?
Impaired physical mobility relative to muscle rigidity.
Risk for aspiration relative to muscle weakness.
Risk for constipation relative to immobility.
Self-care deficit relative to motor disturbance.
The Correct Answer is B
Choice A rationale: Impaired physical mobility is a significant concern in Parkinson's disease due to bradykinesia and tremors. However, it does not pose an immediate threat to life when compared to potential airway and respiratory complications.
Choice B rationale: Aspiration is the highest priority according to the ABC (Airway, Breathing, Circulation) framework. Parkinson's causes dysphagia and impaired laryngeal reflexes, making silent aspiration and subsequent pneumonia a life-threatening risk for the client.
Choice C rationale: Constipation is common due to decreased GI motility and side effects of dopaminergic medications. While it causes discomfort and potential impaction, it is a physiological need that ranks lower than respiratory safety.
Choice D rationale: Self-care deficits in hygiene and dressing affect the client's quality of life and independence. In the hierarchy of care, these functional limitations are addressed only after the client's physical safety and airway are secured.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. Antihypertensive drugs typically work by reducing blood pressure through various mechanisms, such as dilating blood vessels, reducing blood volume, or affecting the heart's workload. They do not increase blood flow to the heart and kidneys.
Choice B rationale:
This is the correct answer. Antihypertensive drugs work by affecting different aspects of the cardiovascular system, such as reducing blood vessel constriction (vasodilation), decreasing blood volume, or slowing the heart rate. By affecting these components, they can lower blood pressure.
Choice C rationale:
This statement is incorrect. Antihypertensive drugs can interact with other medications or supplements, potentially causing adverse effects or drug interactions. It's essential for the client to inform their healthcare provider of all medications and supplements they are taking to ensure safe and effective treatment.
Choice D rationale:
This statement is incorrect. Antihypertensive drugs do not cure hypertension but help control it. Clients need to understand that they will likely need to take these medications long-term to manage their blood pressure effectively.
Correct Answer is B
Explanation
The correct answer is B
Choice A reason: Vasopressin is not typically associated with decreasing GI cramping and nausea. It is used to treat diabetes insipidus and to reduce stomach bloat for some procedures and after some surgeries.
Choice B reason: Vasopressin can cause chest pain or pressure, and fast, slow, or abnormal heartbeat, which are indicative of dysrhythmia. These are known side effects of vasopressin and should be monitored during IV infusion.
Choice C reason: Vasopressin causes vasoconstriction, not vasodilation. It tightens small blood vessels, which is the opposite of vasodilation.
Choice D reason: While vasopressin can cause bradycardia (slow heart rate), hypotension is not a common effect as it is used to treat low blood pressure. Tachycardia (fast heart rate) is not a typical side effect of vasopressin.
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