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 ["A","B","E","G"]
Explanation
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.
Correct Answer is ["D","E","F"]
Explanation
Choice A reason: A tongue blade is not typically necessary for a patient with status epilepticus. It is more commonly used for oral care or to check the throat, but it is not essential in this context.
Choice B reason: A urinary catheter is not necessary unless the patient has specific urinary retention issues or requires accurate measurement of urine output. It is not standard equipment for managing status epilepticus.
Choice C reason: A nasogastric tube is not typically required for status epilepticus unless there are specific gastrointestinal issues that need to be addressed. It is not standard equipment for managing status epilepticus.
Choice D reason: A suction set up is essential for a patient with status epilepticus to manage potential airway secretions and prevent aspiration. It ensures that the airway remains clear and reduces the risk of complications.
Choice E reason: An oxygen mask is crucial for a patient with status epilepticus to ensure adequate oxygenation. It helps maintain oxygen levels and supports respiratory function, especially if the patient experiences respiratory distress.
Choice F reason: Side-rail pads are important for patient safety, particularly for a patient with status epilepticus who may be at risk of falls or injury during seizures. They provide a protective barrier and help prevent accidental injury.
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