The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?
Plan to assess the client's cognition after returning to the room.
Confirm that this is an effective technique to help with ambulation.
Assist the client to a carpeted area to walk more easily.
Reorient the client to the present location and circumstances.
The Correct Answer is B
A. Assessing the client's cognition may be appropriate if there are concerns about cognitive function, but in this scenario, the client's response indicates a coping mechanism for freezing episodes rather than cognitive impairment.
B. Confirming that the client's technique of pretending to step over a crack is an effective strategy acknowledges the client's self-initiated coping mechanism for freezing episodes, which can help promote independence in ambulation.
C. Assisting the client to a carpeted area may help reduce the risk of falls but does not directly address the freezing episode or the client's coping strategy.
D. Reorienting the client to the present location and circumstances is unnecessary as the client's response indicates a conscious coping strategy rather than confusion or disorientation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Palpating the right flank for tenderness is essential to assess for possible renal involvement, such as a kidney infection or kidney stone, which could be causing the urinary symptoms and right lower back pain. However, it is not the initial step.
B. Testing the urine for the presence of hematuria is important in assessing for potential urinary tract infection or other renal pathology but does not directly address the cause of the right lower back pain.
C. Evaluating the urine for a strong odor may provide information about a possible urinary tract infection, but it is not the most immediate intervention for addressing the client's symptoms, compared to measuring the vital signs.
D. Measuring the temperature and pulse rate is important for identifying any signs of systemic infection or inflammation that could be contributing to the patient's symptoms.
Correct Answer is B
Explanation
A. Alternating IV and IM analgesic medications may be appropriate for pain management in some situations but is not the best initial intervention for continuous, severe pain in a client with stage IV bone cancer.
B. Administering opioid and non-opioid medication simultaneously is an appropriate intervention for managing severe pain, as it addresses pain from multiple pathways and may provide more effective pain relief.
C. Giving maximum dosage when the pain score reaches 10 is not recommended, as it may lead to overmedication and increased risk of adverse effects. Pain management should be based on the client's reported pain intensity and individualized needs.
D. Educating the client on signs and symptoms of narcotic dependency is important but is not the priority intervention in this situation. Pain management and relief should be the immediate focus for the client's comfort and quality of life.
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