In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?
Impaired physical mobility relative to muscle rigidity.
Risk for aspiration relative to muscle weakness.
Risk for constipation relative to immobility.
Self-care deficit relative to motor disturbance.
The Correct Answer is B
Choice A rationale: Impaired physical mobility is a significant concern in Parkinson's disease due to bradykinesia and tremors. However, it does not pose an immediate threat to life when compared to potential airway and respiratory complications.
Choice B rationale: Aspiration is the highest priority according to the ABC (Airway, Breathing, Circulation) framework. Parkinson's causes dysphagia and impaired laryngeal reflexes, making silent aspiration and subsequent pneumonia a life-threatening risk for the client.
Choice C rationale: Constipation is common due to decreased GI motility and side effects of dopaminergic medications. While it causes discomfort and potential impaction, it is a physiological need that ranks lower than respiratory safety.
Choice D rationale: Self-care deficits in hygiene and dressing affect the client's quality of life and independence. In the hierarchy of care, these functional limitations are addressed only after the client's physical safety and airway are secured.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
The educational materials should contain a list with definitions of unfamiliar terms because older clients may not be familiar with medical terminology. Providing definitions can enhance their understanding of the new antihypertensive medications and promote medication adherence.
Choice B rationale:
Writing materials at a twelfth-grade reading level may not be appropriate for older clients. Many older individuals may have lower literacy levels, and using complex language can lead to confusion and hinder comprehension. Simple and clear language is more effective in educating this population.
Choice C rationale:
Using common words with few syllables is important for ensuring that older clients can easily understand the educational materials. Complex language and lengthy words can make it difficult for them to grasp important information about their antihypertensive medications.
Choice D rationale:
Using pictures to help illustrate complex ideas is essential when educating older clients. Visual aids can enhance comprehension and retention of information, especially for individuals who may have cognitive impairments or difficulty with written text.
Choice E rationale:
Printing materials using a 12-point type font is important for ensuring that the text is easy to read for older clients. Smaller fonts can be challenging for individuals with visual impairments, and readability is crucial for effective education.
Correct Answer is B
Explanation
- A bowel patern is the frequency, consistency, and appearance of a person's bowel movements. A normal bowel patern is what's normal for each person, and it can vary depending on factors such as diet, age, physical activity, and health conditions.
- A focused gastrointestinal system assessment includes collecting subjective data about the patient's history of gastrointestinal disease, signs and symptoms of gastrointestinal problems, diet and nutrition, and bowel patern. It also includes inspecting and auscultating the abdomen for any abnormalities³.
- When a client reports having a bowel movement three days ago, the first action that the practical nurse should implement is to determine the client's usual bowel patern. This will help to evaluate if the client is experiencing constipation or if this is their normal frequency. It will also help to identify any changes or risk factors that may affect the client's bowel function.
Therefore, option B is the correct answer, while options A, C, and D are incorrect.
Option A is incorrect because administering a stool softener without assessing the client's bowel patern may not be appropriate or effective.
Option C is incorrect because encouraging ambulation may help to stimulate bowel activity, but it is not the first action to take.
Option D is incorrect because recommending dietary changes may be helpful for preventing or treating constipation, but it is not the first action to take.
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