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.

Answer and Explanation

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.

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Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Monitoring the client’s white blood cell count is important in this case. An elevated white blood cell count is a common sign of infection, and regular monitoring can help assess the client’s response to treatment.
Choice B rationale
Implementing contact precautions for staff and visitors is crucial when caring for a client with a potential VRE infection. VRE is a multi-drug resistant organism that can be spread through direct contact, so strict infection control measures are necessary.
Choice C rationale
Using standard precautions and wearing a mask is generally good practice in healthcare settings to prevent the spread of infections. However, a mask is not specifically required for contact precautions with VRE456.
Choice D rationale
Explaining the purpose of a low bacteria diet is not relevant in this case. While diet can play a role in overall health and recovery, it is not a specific intervention for a client with a potential VRE infection.
Choice E rationale
Sending wound drainage for culture and sensitivity is an important step in confirming the presence of VRE and determining the most effective antibiotic therapy.

A. Cease the use of the nasal cannula. B. Reduce the flow rate to 1 L/minute. C. Apply lubricant to the cannula tubing. D. Attach padding around the cannula tubing.

Correct Answer is D

Explanation

Choice A rationale
Ceasing the use of the nasal cannula would interrupt the client’s oxygen therapy, which could potentially worsen their condition. Therefore, this is not the best course of action.
Choice B rationale
Reducing the flow rate to 1 L/minute may not be appropriate as the client’s oxygen needs may not be met at a lower flow rate. The redness under the chin is likely due to the friction from the cannula tubing, not the flow rate of the oxygen.
Choice C rationale
Applying lubricant to the cannula tubing may not be effective in preventing skin breakdown and could potentially cause additional discomfort or complications for the client.
Choice D rationale
Attaching padding around the cannula tubing can help reduce the friction between the tubing and the skin, which can help prevent skin breakdown. This is the most appropriate action to take in this situation.

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When formulating a nursing care plan for a client diagnosed with Parkinson’s disease, which nursing problem should be given the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

The nurse notices redness under the chin of a client who is receiving oxygen at 2 L/minute via a nasal cannula. What action should the nurse take?

Correct Answer is D

Explanation

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