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 B
Explanation
Choice A reason: Reassessing vital signs in 1 hour is not an immediate action and does not address the patient’s current symptoms of dizziness and unsteady gait, which indicate a potential problem that requires immediate attention. Waiting an hour to reassess may delay necessary interventions that could prevent harm.
Choice B reason: Assisting the patient into a sitting position and notifying the healthcare provider is the most appropriate action. The symptoms of dizziness and unsteady gait, along with a BP of 98/60 mmHg, suggest that the patient may be experiencing orthostatic hypotension or a side effect of Carbidopa-Levodopa. Elevating the patient's position can help prevent falls, and notifying the healthcare provider ensures that the situation is assessed and managed promptly. This action addresses the immediate safety of the patient and facilitates appropriate medical intervention.
Choice C reason: Administering the next dose of Carbidopa-Levodopa early is not recommended without specific orders from the healthcare provider. It could potentially lead to overmedication and worsen the patient’s symptoms or cause adverse effects. Medication administration should always follow the prescribed schedule unless otherwise directed by the healthcare provider.
Choice D reason: Educating the patient about increasing his exercise is important for overall health and mobility but is not an immediate intervention for the acute symptoms of dizziness and unsteady gait. The patient’s current condition requires prompt assessment and intervention rather than education on exercise, which can be addressed later once the immediate issue is managed.
Correct Answer is D
Explanation
Choice A reason: "It must have been from sharing needles with my roommate." This statement is incorrect because hepatitis A is not typically transmitted through sharing needles. Hepatitis A is primarily spread through the fecal-oral route, which involves ingestion of contaminated food or water.
Choice B reason: "It is likely transmitted through kissing or sexual activity." This statement is also incorrect. Hepatitis A is not commonly spread through kissing or sexual activity. It is mainly transmitted through consuming contaminated food or water or close contact with an infected person.
Choice C reason: "I think I caught it because I have a family history of liver problems." This statement reflects a misunderstanding of how hepatitis A is transmitted. Hepatitis A is not linked to genetic predisposition or family history of liver problems. It is an infectious disease spread through the fecal-oral route.
Choice D reason: "I probably got it from drinking contaminated water or eating food handled by someone who didn't wash their hands properly." This statement is correct and indicates an accurate understanding of how hepatitis A is transmitted. The virus is often spread through consumption of contaminated food or water, particularly in areas with poor sanitation.
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