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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Collecting the blood sample from a reddened and engorged fingertip may lead to inaccurate glucose readings and can cause discomfort to the client. Selecting another finger is a more appropriate action.
B. Selecting another finger ensures an accurate blood sample and minimizes discomfort to the client. It allows for a fresh puncture site that is not engorged, improving the accuracy of the glucose reading.
C. Applying pressure to the site may temporarily reduce engorgement but may not be sufficient to obtain an accurate blood sample. Selecting another finger is a more appropriate action.
D. Assessing radial pulse volume is not necessary in this situation, as the client's fingertip appearance does not indicate compromise of peripheral circulation.
Correct Answer is D
Explanation
A. Avoiding tight-fitting clothes can help reduce intra-abdominal pressure, which may contribute to GERD symptoms, but it is not the most crucial instruction.
B. Minimizing intake of spicy foods can help decrease gastric irritation and reflux symptoms, but it is not the most important instruction.
C. Beginning a smoking cessation program is important for overall health and may help reduce GERD symptoms, but it is not the most critical instruction for managing GERD.
D. Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter. This instruction helps minimize reflux episodes and should be emphasized to the client with GERD.
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