A 71-year-old male client with moderate to late-stage Parkinson disease is admitted from home to the hospital with new-onset orthostatic hypotension and occasional dysphagia. According to his wife, he needs assistance with ADLs only on days when his rigidity is worse, and walks short distances in the house using a walker. Which of the following actions would the nurse take? Select all that apply.
Consult with the speech-language pathologist for a swallowing evaluation.
Place the client on the hospital's fall precautions protocol.
Obtain a prescription for a different antihypertensive medication.
Remind the nursing staff to place the client in a sitting position during meals.
Refer the client for physical and occupational therapy evaluations.
Place the client on a liquid diet to prevent choking.
Perform orthostatic blood pressure checks.
Correct Answer : A,B,E,G
Choice A reason: Consulting with the speech-language pathologist for a swallowing evaluation is essential because the client has occasional dysphagia. Swallowing difficulties can lead to aspiration and other complications, and a proper evaluation can help determine the safest diet and interventions.
Choice B reason: Placing the client on the hospital's fall precautions protocol is crucial due to the client's orthostatic hypotension and use of a walker. These factors increase the risk of falls, and implementing fall precautions can help prevent injuries.
Choice C reason: Obtaining a prescription for a different antihypertensive medication is not indicated in this scenario. There is no information provided that suggests the current medication is inappropriate or ineffective. The focus should be on managing the client's orthostatic hypotension with non-pharmacological interventions.
Choice D reason: Reminding the nursing staff to place the client in a sitting position during meals is important to reduce the risk of aspiration due to dysphagia. Sitting upright can help ensure that food and liquids are swallowed safely.
Choice E reason: Referring the client for physical and occupational therapy evaluations is necessary to address the client's functional mobility and ability to perform ADLs. These therapies can help optimize the client's independence and safety.
Choice F reason: Placing the client on a liquid diet to prevent choking is not appropriate without a swallowing evaluation. The speech-language pathologist should determine the safest diet based on the client's specific needs and swallowing abilities.
Choice G reason: Performing orthostatic blood pressure checks is important for monitoring and managing the client's orthostatic hypotension. Regular checks can help identify changes in blood pressure and guide interventions to prevent falls and related complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A reason: ACE inhibitors are primarily used to treat high blood pressure and heart failure, but they are not typically the first line of treatment for peripheral artery disease (PAD). While they may be prescribed to manage underlying conditions that contribute to PAD, they are not specifically targeted at improving blood flow in the affected arteries.
Choice B reason: Antibiotics are used to treat bacterial infections and have no role in the management of peripheral artery disease (PAD). They do not address the underlying causes or symptoms of PAD and are not included in the treatment regimen for this condition.
Choice C reason: Statins are commonly prescribed to patients with peripheral artery disease (PAD) as they help lower cholesterol levels and reduce the risk of plaque buildup in the arteries. By lowering LDL cholesterol and stabilizing plaques, statins can improve blood flow and reduce the progression of PAD.
Choice D reason: Beta-blockers are used to manage high blood pressure and heart conditions, but they are not typically used as a primary treatment for peripheral artery disease (PAD). While they may be prescribed to manage underlying cardiovascular conditions, they do not directly improve blood flow in the affected arteries.
Choice E reason: Antiplatelet agents, such as aspirin and clopidogrel, are commonly prescribed to patients with peripheral artery disease (PAD) to prevent blood clots from forming in the arteries. By inhibiting platelet aggregation, these medications help improve blood flow and reduce the risk of complications associated with PAD.
Correct Answer is C
Explanation
Choice A reason: Increased serum chloride is not a typical finding associated with syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, the body's regulation of water is impaired, leading to water retention and dilutional hyponatremia. Serum chloride levels might not be significantly affected and are not the primary laboratory indicator for this condition.
Choice B reason: Elevated hematocrit is not directly related to SIADH. Hematocrit levels reflect the proportion of red blood cells in the blood. In SIADH, the main issue is water retention leading to dilutional hyponatremia, rather than changes in red blood cell concentration. Therefore, hematocrit levels are not a key laboratory finding in this disorder.
Choice C reason: Decreased serum sodium, or hyponatremia, is a hallmark finding in SIADH. The excessive release of antidiuretic hormone (ADH) leads to water retention, diluting the sodium in the blood and resulting in low serum sodium levels. This hyponatremia can cause symptoms such as disorientation, headache, and muscle cramps, as seen in the patient. Monitoring and correcting serum sodium levels is crucial in the management of SIADH.
Choice D reason: Low urine specific gravity is not expected in SIADH. In fact, patients with SIADH typically have a high urine specific gravity due to the excessive release of ADH, which causes the kidneys to reabsorb water and concentrate the urine. This concentrated urine reflects the body's attempt to reduce water excretion in response to elevated ADH levels. Therefore, low urine specific gravity would not be an initial laboratory finding in this condition.
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