What is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post- thyroidectomy?

Choice A rationale

While constipation due to immobility can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should ensure that the client has a diet high in fiber and drinks plenty of fluids to prevent constipation. Regular physical activity can also help to stimulate bowel movements. However, this is not the most critical issue that needs to be addressed.

Choice B rationale

The risk for aspiration due to muscle weakness is the highest priority for a client diagnosed with Parkinson’s disease. This is because Parkinson’s disease can cause difficulties with swallowing, which can lead to aspiration. Aspiration can lead to serious complications such as pneumonia. The nurse should monitor the client for signs of difficulty swallowing and aspiration. The client may need to be referred to a speech therapist for a swallowing evaluation and may need modifications to their diet to make swallowing easier.

Choice C rationale

While impaired physical mobility due to muscle rigidity can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should encourage the client to engage in regular physical activity to help manage muscle rigidity. Physical therapy may also be beneficial. However, this is not the most critical issue that needs to be addressed.

Choice D rationale

While a self-care deficit due to motor disturbance can be a concern for a client diagnosed with Parkinson’s disease, it is not the highest priority. The nurse should assess the client’s ability to perform activities of daily living and provide assistance as needed. Occupational therapy may also be beneficial. However, this is not the most critical issue that needs to be addressed.

Choice A rationale
Using a cushion when sitting can provide comfort but does not directly address the client’s electrolyte imbalance, elevated blood pressure, or weight gain.

Choice B rationale
Offering a high protein diet can be beneficial for clients with hepatic failure to support liver regeneration and prevent malnutrition. However, it does not directly address the client’s immediate issues.

Choice C rationale

Providing only distilled water does not address the client’s electrolyte imbalance, elevated blood pressure, or weight gain. In fact, it could potentially exacerbate electrolyte imbalances.

Choice D rationale
Documenting abdominal girth can help monitor for fluid accumulation (ascites), a common complication of hepatic failure that can contribute to weight gain and elevated blood pressure.