A client with influenza requires assistance in transferring to the bedside commode.
The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the client. What action should the nurse take?

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.

Choice A rationale
Hyperventilation leads to a decrease in the amount of carbon dioxide (CO2) in the blood. This causes the pH of the blood to increase, resulting in respiratory alkalosis.
Choice B rationale
Respiratory acidosis is caused by a buildup of CO2 in the blood, typically due to hypoventilation (under-breathing). This is not consistent with the patient’s symptoms of hyperventilation.
Choice C rationale
Metabolic alkalosis is typically caused by a significant loss of acid from the body, such as from prolonged vomiting. This is not consistent with the patient’s symptoms.

Choice D rationale
Metabolic acidosis is typically caused by an increase in acid production within the body or a loss of bicarbonate from the body, such as in diabetic ketoacidosis or kidney disease. This is not consistent with the patient’s symptoms.