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 A
Explanation
Choice A rationale
Testing the fluid on the dressing for glucose is the immediate course of action when a nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. Clear fluid could be cerebrospinal fluid (CSF), which contains glucose. If the fluid is positive for glucose, it could indicate a CSF leak, which requires immediate medical attention.
Choice B rationale
Changing the dressing using a compression bandage is not the immediate course of action. The source of the fluid needs to be identified first.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate course of action. The source of the fluid needs to be identified first.
Choice D rationale
Documenting the findings in the electronic medical record is important, but it is not the immediate course of action. The source of the fluid needs to be identified first.
Correct Answer is B
Explanation
Choice A rationale
Gastric lavage is a procedure that involves the insertion of a tube into the stomach to remove its contents and is typically used in cases of poisoning or drug overdose. However, it should not be the first action taken. The type of chemical exposure needs to be determined first to guide appropriate treatment.
Choice B rationale
Determining the type of chemical exposure is crucial as it guides the subsequent steps in management. Different chemicals can have different effects on the body and require different treatments.
Choice C rationale
While assessing for altered sensorium is important in a child exposed to chemicals, it is not the first action. The nurse needs to identify the type of chemical the child was exposed to in order to anticipate potential complications and guide treatment.
Choice D rationale
Calling the poison control emergency number is an important step in managing a case of chemical exposure. However, having information about the type of chemical the child was exposed to can make this call more effective.
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