A client with Parkinson’s disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective?
Telling his wife what the client needs.
Setting up visitations by a home health nurse.
Involving the client and his wife in developing a plan of care.
Writing up a detailed plan of care according to standards.
The Correct Answer is C
Choice A Reason:
Telling his wife what the client needs is not the most effective discharge action. While it is important for the wife to understand the client’s needs, this approach is too passive and does not actively engage the client or his wife in the care process. Effective management of Parkinson’s disease requires active participation from both the client and the caregiver to ensure adherence to the care plan and to address any concerns or preferences they may have.
Choice B Reason:
Setting up visitations by a home health nurse can be beneficial, but it is not the most effective discharge action on its own. Home health nurses can provide valuable support and monitoring, but the success of the management plan also depends on the involvement and commitment of the client and his wife. Without their active participation, the care plan may not be fully effective.
Choice C Reason:
Involving the client and his wife in developing a plan of care is the most effective discharge action. This approach ensures that both the client and his wife are fully engaged in the care process, understand the management plan, and are more likely to adhere to it. Collaborative care planning allows for the consideration of the client’s and caregiver’s preferences, needs, and concerns, leading to a more personalized and effective care plan. This active involvement can also empower the client and his wife, improving their confidence in managing the disease.
Choice D Reason:
Writing up a detailed plan of care according to standards is important, but it is not the most effective discharge action if done in isolation. A standardized care plan may not address the unique needs and preferences of the client and his wife. Without their involvement in the development of the plan, there may be a lack of understanding or commitment to the care plan, reducing its effectiveness. Personalizing the care plan through active involvement of the client and his wife is crucial for successful management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Tachycardia
Tachycardia, defined as a heart rate exceeding 100 beats per minute, can affect the accuracy of pulse oximetry readings. When the heart beats too quickly, it may not fill with enough blood between beats, leading to reduced perfusion and oxygen delivery to tissues. However, while tachycardia can influence the readings, it is not the most significant factor compared to hypotension.
Choice B: Hypotension
Hypotension, or low blood pressure, significantly impacts pulse oximetry accuracy. When blood pressure is low, there is reduced perfusion to peripheral tissues, including the extremities where pulse oximeters are typically placed. This reduced perfusion can lead to inaccurate readings, as the device may not detect sufficient blood flow to measure oxygen saturation accurately. Hypotension is a critical factor that can alter pulse oximetry values, making it the most relevant choice.
Choice C: Tachypnea
Tachypnea, or rapid breathing, can affect oxygen levels in the blood but does not directly interfere with the pulse oximeter’s ability to measure oxygen saturation. While it indicates respiratory distress and can lead to hypoxemia, the pulse oximeter can still provide accurate readings unless accompanied by other factors like low perfusion.
Choice D: Fever
Fever can cause peripheral vasodilation, which might theoretically affect pulse oximetry readings by altering blood flow to the extremities. However, this effect is generally minimal compared to the impact of hypotension. Fever alone is unlikely to cause significant inaccuracies in pulse oximetry measurements.
Correct Answer is B
Explanation
Choice A reason:
Elevating the head of the client’s bed can help reduce blood pressure slightly by promoting venous return and decreasing intracranial pressure. However, this action alone is not sufficient to address the severe hypertension (254/139 mm Hg) the client is experiencing. Immediate medical intervention is required to prevent complications such as stroke, heart attack, or organ damage.
Choice B reason:
Contacting the Rapid Response Team is the highest priority action. The Rapid Response Team is trained to handle critical situations and can provide immediate interventions to stabilize the client’s condition. Severe hypertension at this level requires urgent medical attention to prevent life-threatening complications. The team can administer medications to lower blood pressure quickly and monitor the client closely.
Choice C reason:
Telling the client to report vision changes is important because vision changes can indicate hypertensive retinopathy or increased intracranial pressure. However, this action is not the immediate priority. The client’s blood pressure needs to be controlled urgently to prevent further complications.
Choice D reason:
Inserting a peripheral IV is necessary for administering medications and fluids. While this is an important step, it should follow the immediate action of contacting the Rapid Response Team. The team can then use the IV access to administer antihypertensive medications promptly.
Choice E reason:
Initiating seizure precautions is important because severe hypertension can lead to seizures. However, this action is not the first priority. The primary focus should be on stabilizing the client’s blood pressure through immediate medical intervention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today