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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. Starting two large bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is essential in the immediate management of a client with sudden, severe headache and neurological deficits suggestive of stroke. Time- sensitive interventions, such as IV fibrinolytic therapy, may be indicated if the client meets criteria for treatment.

B. Administering aspirin to prevent further clot formation and platelet clumping is contraindicated in the acute management of a suspected stroke until hemorrhagic stroke is ruled out.

C. Verifying prescribed laboratory tests include prothrombin time and platelet count is important for assessing coagulation status, but it is not the immediate intervention needed in this situation.

D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority intervention in the acute management of a suspected stroke.

A. The client's blood pressure readings will be less than 160/90 mm Hg. B. The nurse will encourage the client to walk thirty minutes every day. C. The client's family will repeat signs and symptoms about the disease. D. The client's daily blood pressure will be less than 140/80 mm Hg this month.

Correct Answer is D

Explanation

A. While controlling blood pressure is important in managing cardiovascular disease, the specific outcome should reflect the target blood pressure goal of less than 140/80 mm Hg to reduce the risk of complications.

B. Encouraging physical activity is beneficial for cardiovascular health, but the outcome should focus on blood pressure management, which is more directly related to the client's reported symptoms of blurred vision.

C. Educating the client's family about signs and symptoms of cardiovascular disease is important for support, but it does not directly address the client's blurred vision or cardiovascular risk factors.

D. Achieving a daily blood pressure reading of less than 140/80 mm Hg is an appropriate outcome to ensure adequate control of blood pressure and reduce the risk of cardiovascular complications, including those that may contribute to blurred vision.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is D

Explanation

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