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 B
Explanation
A. Documenting the client's loss of memory is important for ongoing assessment, but it is not the immediate action to take when the client is confused about the day of the week.
B. Reminding the client of the day of the week is a direct intervention to help orient the client, which is a primary approach for managing acute confusion or disorientation.
C. Notifying the family of the change in the client’s condition may be necessary if confusion persists or worsens, but initial steps should focus on immediate management of the confusion.
D. Encouraging the client to rest is a general supportive action but does not address the specific issue of confusion about the day of the week.
Correct Answer is B
Explanation
A. Maintaining low intermittent suction requires assessing the appropriate suction settings and monitoring for complications, which are responsibilities beyond the UAP’s scope of practice. This task involves clinical judgment and knowledge of suction settings.
B. Securing the tube to the client’s nose is a task that UAPs can perform. It is a straightforward task that helps ensure the tube stays in place, which is a supportive care measure within the UAP's scope of practice.
C. Ensuring correct placement of the tube involves assessing for proper tube position through methods such as aspirating gastric contents or using imaging, which are tasks that require clinical judgment and are outside the UAP's scope of practice.
D. Replacing the canister when full involves handling medical equipment and requires understanding of suction mechanics and infection control practices, which are tasks that the PN or RN should perform.
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