When formulating a nursing care plan for a client diagnosed with Parkinson’s disease, which nursing problem should be given the highest priority?
Risk for constipation due to immobility.
Risk for aspiration due to muscle weakness.
Impaired physical mobility due to muscle rigidity.
Self-care deficit due to motor disturbance.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While obtaining an analgesic prescription might help to alleviate the client’s joint pain, it is not the first intervention that should be implemented. The client’s vital signs indicate that they are in a state of shock, which is a medical emergency.
Choice B rationale
Infusing an intravenous fluid bolus is often the first step in treating shock. The client’s low blood pressure and high heart rate suggest that they may be experiencing hypovolemic shock, which can be caused by a severe fluid loss. Administering fluids can help to increase blood volume and improve blood pressure.
Choice C rationale
Administering a PRN oral antipyretic would not address the client’s immediate need. The client’s high temperature is a concern, but the low blood pressure and high heart rate are more immediate concerns.
Choice D rationale
Covering the client with a cooling blanket would address the client’s high temperature, but it would not address the more immediate concerns of low blood pressure and high heart rate.
Correct Answer is A
Explanation
Choice A rationale
Reassuring the adolescent that experiencing phantom limb pain can be a normal post-surgical sensation is the correct choice. Phantom limb pain is a common occurrence after amputation and can be very distressing for the patient. The nurse should validate the patient’s experience and provide reassurance. Non-pharmacological interventions such as mirror therapy, visualization, and other cognitive-behavioral strategies can also be helpful.
Choice B rationale
Guiding the patient in moving the non-affected limb to override the sensation being experienced is not the most appropriate intervention. While some therapies for phantom limb pain involve focusing on the remaining limb, this should be done under the guidance of a trained therapist.
Choice C rationale
Telling the patient that the sensations of tingling and pain are not real is not an appropriate intervention. Although the limb is no longer there, the pain that the patient is experiencing is very real. It is important to validate the patient’s experience and provide appropriate interventions.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is not the most appropriate intervention. While using a prosthetic and engaging in physical therapy can help with overall recovery and adaptation after amputation, they do not directly address phantom limb pain. The pain is a result of mixed signals from the brain and nerves, and it requires specific interventions.
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