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. Protect the skin of the radiation portal site from sunlight exposure. B. Avoid washing the skin inside the radiation portal site. C. Remove the ink marks of the portal after each radiation treatment. D. Apply moisture lotions daily to the radiation portal site.

Correct Answer is A

Explanation

A. Protecting the skin of the radiation portal site from sunlight exposure is crucial to prevent further damage to the irradiated area, as the skin becomes more sensitive during radiation therapy.

B. Washing the skin inside the radiation portal site should be done gently with mild soap and water, as directed by the healthcare provider, to maintain cleanliness and prevent infection. However, excessive rubbing or scrubbing should be avoided to minimize irritation.

C. The ink marks of the portal are used as reference points for accurate delivery of radiation and should not be removed until instructed by the healthcare provider or radiation therapist.

D. Moisturizing the radiation portal site can help alleviate dryness and discomfort associated with radiation therapy, but it should be done sparingly and with products recommended by the healthcare provider to avoid potential interactions or interference with the treatment.

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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 caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

Correct Answer is A

Explanation

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