A client with Parkinson's disease is experiencing decreased postural reflexes, rigidity, retropulsive gait, and shuffling. Which intervention is most important for the practical nurse (PN) to implement?
Fall precautions.
Aspiration precautions.
Reorientation cues.
Bowel training.
The Correct Answer is A
A. Implementing fall precautions is the most important intervention for a client with Parkinson’s disease experiencing decreased postural reflexes, rigidity, and gait issues. These symptoms significantly increase the risk of falls, so fall precautions are crucial for preventing injury.
B. Aspiration precautions are important for many clients, but they are less immediately relevant in this context compared to fall prevention. The symptoms listed do not directly indicate a high risk of aspiration.
C. Reorientation cues may be necessary for clients with cognitive issues but are not the primary concern for managing motor symptoms like those listed. The focus here should be on physical safety rather than cognitive orientation.
D. Bowel training is a useful intervention for managing bowel function but is not directly related to the acute risks of fall and gait disturbances associated with Parkinson’s disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A, C, B, D
Explanation
A. Informing the client of the purpose of the medication is the first step. This action ensures that the client understands why they are receiving the medication and what it is intended to do.
C. Putting on a clean pair of gloves is the next step to maintain hygiene and prevent contamination while handling the medication and applying the patch.
B. Placing the patch on a new area of cleansed skin follows glove application. Ensuring that the skin is clean and that a new site is used prevents irritation and ensures the effectiveness of the medication.
D. Documenting the application in the electronic medication record is the final step to complete the medication administration process. This ensures that the medication administration is recorded accurately for future reference and compliance.
Correct Answer is A
Explanation
A. Acceleration refers to a temporary increase in the fetal heart rate of at least 15 beats per minute above the baseline for at least 10 seconds. The observation of the fetal heart rate increasing 15 beats above baseline twice during the test indicates that accelerations are present, which is a reassuring sign of fetal well-being.
B. A nonreactive pattern would indicate that the test did not meet the criteria for accelerations or fetal heart rate reactivity, which is not the case here as the fetal heart rate did exhibit accelerations.
C. Fetal movement could contribute to accelerations but is not the term used to describe the findings of the test itself. The specific observation made was an increase in fetal heart rate, which is classified as an acceleration.
D. A positive tracing indicates that the nonstress test met criteria for fetal well-being, typically with at least two accelerations, but the correct term for the specific observation here is acceleration rather than describing the overall result.
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