A new nurse in a long-term care facility is caring for a client diagnosed with Parkinson's disease (PD). The nurse should note that which one of the following actions is likely to be observed during the assessment?
Changing facial expression
Frequent movement
Resting hand tremors
Fast movements
None of the above
The Correct Answer is C
Choice A reason: Changing facial expression is not a likely action to be observed during the assessment, as PD causes reduced facial expression or mask-like face. The client may have difficulty blinking, smiling, or showing emotions.
Choice B reason: Frequent movement is not a likely action to be observed during the assessment, as PD causes slowed movement or bradykinesia. The client may have difficulty initiating, continuing, or completing movements.
Choice C reason: Resting hand tremors is a likely action to be observed during the assessment, as PD causes rhythmic shaking of the hands, fingers, or other body parts. The tremors usually occur when the affected limb is at rest and may decrease when the client is performing tasks.
Choice D reason: Fast movements is not a likely action to be observed during the assessment, as PD causes impaired movement or dyskinesia. The client may have involuntary, jerky, or twisting movements that are often unpredictable and uncontrollable.
Choice E reason: None of the above is not the correct answer, as there is one choice that is a likely action to be observed during the assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Position the client to achieve their comfort is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Comfort is important, but not the priority in this situation.
Choice B reason: Offer toileting and a sip of water is not the most important intervention, as it does not address the potential risks of opioid analgesics, such as respiratory depression, sedation, and falls. Toileting and hydration are important, but not the priority in this situation.
Choice C reason: Place side rails up x 4 is not the most important intervention, as it may not prevent the client from getting out of bed and falling. Side rails may also be considered a restraint, which can increase the risk of injury and agitation. Side rails are not a substitute for proper supervision and assistance.
Choice D reason: Instruct the client to ask for help before getting up is the most important intervention, as it can prevent the client from falling and injuring themselves. Opioid analgesics can impair the client's balance, coordination, and judgment, making them more prone to falls. The nurse should educate the client about the effects of opioids and the importance of asking for help before attempting to get out of bed.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the most important intervention for the nurse to implement before leaving the client’s room.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Physical status is an important assessment for post-fall prevention, as it can identify the possible causes and consequences of the fall, such as injuries, pain, mobility, balance, strength, vision, hearing, cognition, and medication use. Physical status can also help determine the appropriate interventions and referrals for the older adult, such as physical therapy, occupational therapy, or home health care.
Choice B reason: Financial status is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, financial status may influence the older adult's access to health care, social support, and assistive devices, which may affect their recovery and quality of life. Financial status may also be a source of stress or anxiety for the older adult, which may impair their mental and emotional well-being.
Choice C reason: Occupational history is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, occupational history may provide some information about the older adult's past and current activities, skills, and interests, which may help tailor the interventions and goals for the older adult. Occupational history may also reflect the older adult's sense of identity, purpose, and satisfaction, which may affect their motivation and engagement.
Choice D reason: Environment is an important assessment for post-fall prevention, as it can identify the potential hazards and barriers that may contribute to the fall, such as poor lighting, slippery floors, clutter, loose rugs, stairs, or furniture. Environment can also help determine the appropriate modifications and adaptations that can reduce the risk of future falls, such as installing grab bars, handrails, ramps, or alarms. Environment can also influence the older adult's comfort, safety, and independence at home or in other settings.
Choice E reason: None of the above is not the correct answer, as there are two choices that are essential assessments for post-fall prevention.
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