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.
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Correct Answer is D
Explanation
Step 1 is to convert the child’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.2 lbs. So, the child’s weight in kg is 55 lbs ÷ 2.2 = 25 kg (rounded to the nearest whole number for simplicity).
Step 2 is to calculate the total daily dosage. The prescription is for 150 mg/kg/day. So, the total daily dosage is 150 mg/kg/day × 25 kg = 3750 mg/day.
So, the correct answer is, after analysing all choices, the nurse should administer 3750 mg of cefotaxime each day.
Correct Answer is B
Explanation
The correct answer is choice B. “You seem quite frightened right now.”.
Choice A rationale:
While reassuring the client that no one will hurt them is well-intentioned, it may not effectively address the client’s immediate emotional state or validate their feelings.
Choice B rationale:
Acknowledging the client’s fear helps validate their emotions and opens a pathway for further therapeutic communication. It shows empathy and understanding, which can help build trust and provide comfort.
Choice C rationale:
Telling the client they are in a safe place is reassuring, but it may not fully address the client’s immediate emotional distress or validate their feelings.
Choice D rationale:
Asking the client what they would like the nurse to do to protect them might reinforce the delusion and could potentially escalate the situation. It is more effective to acknowledge the client’s feelings and provide reassurance.
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