The nurse is providing education to the client with Parkinson's disease and their family. The nurse understands that teaching has not been effective when the client makes which of the following statements?
"I can sit down to put on my pants and shoes."
"I try to exercise every day and rest when I am tired."
"I do not need to use my walker to go to the bathroom."
"My son removed all the loose rugs from the house."
The Correct Answer is C
Choice A reason: The statement about being able to sit down to put on pants and shoes indicates that the client is implementing safety measures to prevent falls, which is a positive outcome of effective teaching.
Choice B reason: Exercising daily and resting when tired is an appropriate strategy for managing Parkinson's disease symptoms, suggesting that the client has understood the education provided.
Choice C reason: The statement about not needing a walker could indicate a lack of understanding of the importance of mobility aids in preventing falls, which is a concern for clients with Parkinson's disease.
Choice D reason: Removing loose rugs from the house is a preventive measure to reduce fall risk, indicating that the client and family have understood and applied the education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The serum lactate level of 3.9 mmol/L is significantly higher than the normal range of 0.5-2 mmol/L. This is a critical value to report as it indicates a high likelihood of sepsis, which is a life-threatening condition requiring immediate intervention. Elevated lactate levels suggest that the tissues are not adequately oxygenated, a state known as tissue hypoxia, which is a hallmark of sepsis.
Choice B reason: While the vital signs show a slight fever (100°F), the heart rate, respiratory rate, and blood pressure are within normal limits for an adult and do not indicate an immediate life-threatening condition.
Choice C reason: A pulse oximetry reading of 96% on supplemental oxygen is within the acceptable range, indicating adequate oxygen saturation and not a direct sign of sepsis.
Choice D reason: The presence of rhonchi bilaterally suggests airway obstruction due to mucus, which can be associated with pneumonia. However, this finding alone does not carry the same immediate risk of morbidity and mortality as an elevated lactate level indicative of sepsis.
Correct Answer is C
Explanation
Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.
Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.
Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.
Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.
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