Despite numerous instructions, an elderly patient with Parkinson’s disease is unable to administer ophthalmic medication without assistance due to hand tremors.
What is the best course of action for the nurse?
Continue to reinforce the instructions to boost the patient’s self-confidence.
Determine if a family member is available and willing to administer the medication.
Obtain a prescription for a visiting nurse to administer the medication twice a day.
Document the patient’s inability to administer the medication without assistance.
The Correct Answer is B
Answer and explanation
The correct answer is Choice B.
Choice A rationale
While reinforcing instructions can boost a patient’s self-confidence, it may not be effective for an elderly patient with Parkinson’s disease who is unable to administer ophthalmic medication due to hand tremors. The physical limitation caused by the tremors may not be overcome by further instruction.
Choice B rationale
If a family member is available and willing to administer the medication, this could be an effective solution. The family member can be trained to administer the medication correctly, ensuring the patient receives their necessary treatment.
Choice C rationale
While obtaining a prescription for a visiting nurse to administer the medication twice a day could ensure the patient receives their medication, it may not be the most practical or cost- effective solution. It also depends on the availability of such services in the patient’s area.
Choice D rationale
Documenting the patient’s inability to administer the medication without assistance is important for record-keeping and communicating with other healthcare providers. However, it does not address the immediate issue of ensuring the patient receives their necessary medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer and explanation
The correct answer is Choice B.
Choice A rationale
Rechecking the client’s vital signs in 30 minutes may not be the most appropriate action in this situation. The client is showing signs of possible complications such as infection (elevated
temperature, malaise) and referred pain in the shoulder, which could indicate diaphragmatic irritation. These symptoms, along with the client’s recent surgery, suggest that immediate medical attention may be necessary.
Choice B rationale
Having the client transported via ambulance to the hospital is the most appropriate action. The client’s symptoms suggest possible complications that require immediate medical attention.
Abdominal tenderness and shoulder pain could indicate a serious condition such as a perforation or infection. The elevated heart rate and low blood pressure could suggest sepsis or shock. Immediate medical evaluation and treatment are necessary.
Choice C rationale
Determining the client’s current oxygen saturation rate is important, but it is not the most immediate need. While this information could provide additional data about the client’s condition, it does not address the potential seriousness of the client’s symptoms. The client needs immediate medical attention.
Choice D rationale
Instructing the client to drive to the hospital for admission is not the best choice. Given the client’s symptoms and recent surgery, it would be safer for the client to be transported by ambulance. This would ensure that the client receives immediate medical attention and that the client’s condition can be monitored during transport.
Correct Answer is D
Explanation
Answer and explanation
The correct answer is Choice D.
Choice A rationale
Checking the client’s temperature, blood sugar, and urine output could be important in certain situations, but in this case, it may not be the most immediate need. The client is wandering and crying, which suggests emotional distress rather than a physical health issue.
Choice B rationale
Arranging for the client to be transported for laboratory tests and an electrocardiogram (ECG) would be an overreaction in this situation. There’s no indication from the client’s behavior that they are experiencing a medical emergency.
Choice C rationale
Delegating care of the crying client to an unlicensed assistant is not the best choice. The client is likely experiencing emotional distress due to the traumatic event, and they would benefit from the care and attention of a trained professional.
Choice D rationale
Directing the client to the shelter’s nutrition center to obtain water and food is the best action in this situation. The client may be dehydrated or hungry, which could be contributing to their distress. Providing for these basic needs can help to calm the client and provide a sense of safety and stability.
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