The nurse is caring for a client with a history of Parkinson’s disease. Which intervention should the nurse prioritize?
Assist with mobility and fall prevention
Encourage high-protein meals
Restrict fluid intake
Promote social isolation
The Correct Answer is A
Choice A reason: Assisting with mobility and fall prevention is critical in Parkinson’s disease, as bradykinesia and rigidity increase fall risk. Physical therapy and assistive devices enhance safety, reducing injury risk, making this the priority intervention to maintain functional independence and prevent fractures.
Choice B reason: High-protein meals may interfere with levodopa absorption in Parkinson’s, worsening symptoms. Mobility assistance is the priority, as falls are a leading cause of injury, requiring immediate intervention to ensure safety, making dietary protein secondary to physical support.
Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents constipation in Parkinson’s. Mobility and fall prevention are critical, as motor symptoms increase injury risk. Assisting with mobility addresses the primary functional challenge, making fluid restriction irrelevant to priority care.
Choice D reason: Promoting social isolation worsens depression in Parkinson’s, a common comorbidity. Mobility assistance is the priority, as falls due to motor impairment are a significant risk, requiring immediate intervention to ensure safety, making social isolation counterproductive to care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: HIV does not primarily cause a deficiency in antibody production. B-cells produce antibodies, but HIV targets CD4 T-cells, impairing their ability to activate B-cells. This indirectly reduces antibody effectiveness, but the primary mechanism is T-cell destruction, not a direct antibody production deficit, making this incorrect.
Choice B reason: HIV infects and destroys helper T-cells (CD4 cells), critical for coordinating immune responses. By reducing CD4 cell counts, HIV impairs activation of B-cells and cytotoxic T-cells, leading to immune suppression. This is the primary mechanism of AIDS-related immune deficiency, making it the correct explanation for HIV pathology.
Choice C reason: Proliferation of suppressor T-cells (regulatory T-cells) is not a primary HIV mechanism. HIV depletes CD4 cells, not suppressor T-cells, which modulate immune responses. While immune dysregulation occurs, the hallmark is CD4 destruction, not suppressor T-cell proliferation, making this an inaccurate description of HIV’s action.
Choice D reason: HIV does not increase B-lymphocyte numbers. It impairs B-cell function indirectly by destroying CD4 cells, which are needed to activate B-cells for antibody production. B-cell hyperactivity may occur in early HIV, but the primary immune suppression results from CD4 cell loss, not B-cell proliferation.
Correct Answer is C
Explanation
Choice A reason: A numeric pain scale quantifies pain intensity but not its quality, such as burning or stabbing. Descriptive data provide a fuller picture of pain characteristics, which guide treatment. Numbers alone lack the detail needed to assess the nature of the pain experience.
Choice B reason: Observing body language and movement, like grimacing or guarding, indicates pain presence but not its specific quality. Subjective descriptions from the client reveal characteristics like sharpness or throbbing, which are critical for diagnosis and management, making observation secondary to verbal reports.
Choice C reason: Asking the client to describe the pain captures its quality, including type, location, and pattern (e.g., burning, stabbing). This subjective data is essential for diagnosing the pain’s cause and tailoring treatment, as it provides detailed insights beyond intensity or observable signs, making it the best approach.
Choice D reason: Identifying effective pain relief measures is part of pain management, not assessment of pain quality. Understanding the pain’s characteristics through description is necessary before selecting interventions. This approach is premature without first gathering detailed subjective data from the client.
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