A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? The nurse assesses the client after a thoracentesis. Which assessment finding warrants immediate action? You should have 2 responses for this question: 1 for Intervention and 1 for Assessment.

Choice A: Ammonia

Lactulose is administered to patients with hepatic encephalopathy to reduce the levels of ammonia in the blood. Hepatic encephalopathy occurs due to the liver’s inability to detoxify ammonia, a byproduct of protein metabolism. Lactulose works by converting ammonia into ammonium, which is then excreted in the stool. This helps to lower blood ammonia levels and alleviate the symptoms of hepatic encephalopathy.

Choice B: Dysarthria

Dysarthria, or difficulty in articulating words, is a common symptom of Parkinson’s disease. It results from the muscle rigidity and bradykinesia (slowness of movement) that affect the muscles involved in speech. Patients with Parkinson’s often have a soft, monotone voice and may struggle with the clarity of their speech.

Choice C: Muscle Rigidity

Muscle rigidity is one of the hallmark symptoms of Parkinson’s disease. It refers to the stiffness and inflexibility of the muscles, which can affect any part of the body. This rigidity can lead to discomfort and pain, and it contributes to the characteristic stooped posture and shuffling gait seen in Parkinson’s patients.

Choice D: Seizures

Seizures are not typically associated with Parkinson’s disease. While Parkinson’s affects the central nervous system, it primarily impacts motor function rather than causing seizure activity. Therefore, this is not a common finding in Parkinson’s patients.

Choice E: Drooling at Times

Drooling, or sialorrhea, is a common symptom in Parkinson’s disease. It occurs due to the decreased ability to swallow saliva, which can result from muscle rigidity and bradykinesia affecting the muscles involved in swallowing. This can be particularly bothersome for patients and may require management strategies.

Choice F: Mask-like Facial Expression

A mask-like facial expression, also known as hypomimia, is a common feature of Parkinson’s disease. It results from the rigidity and bradykinesia affecting the facial muscles, leading to reduced facial expressions and a fixed, staring appearance.

Choice G: Shuffled Gait

A shuffled gait is a characteristic feature of Parkinson’s disease. Patients often take small, shuffling steps and may have difficulty initiating movement. This gait pattern is due to the combination of muscle rigidity, bradykinesia, and postural instability.

Choice H: Stooped Posture

Stooped posture is another common symptom of Parkinson’s disease. It results from the muscle rigidity and postural instability that affect the patient’s ability to maintain an upright position. This can lead to a forward-leaning posture and balance issues.

Choice A Reason:

The client who displays plantar flexion when the bottom of the foot is stroked is exhibiting a normal reflex response known as the plantar reflex. This response indicates that the corticospinal tract is functioning properly. In adults, the normal response is plantar flexion of the toes, which means the toes curl downward. This is not an immediate cause for concern and does not indicate a life-threatening condition.

Choice B Reason:

The client who consistently demonstrates decortication when stimulated is showing signs of severe brain injury. Decorticate posturing is characterized by the arms being flexed at the elbows and held tightly to the chest, with the legs extended and feet turned inward. This type of posturing indicates damage to the cerebral hemispheres, thalamus, or midbrain. While this is a serious condition, it is not necessarily the most immediate priority compared to a sudden change in the Glasgow Coma Scale.

Choice C Reason:

The client whose Glasgow Coma Scale (GCS) has changed from 15 to 12 is the nurse’s first priority. The GCS is a critical tool used to assess a patient’s level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully awake and alert). A drop in GCS score indicates a significant decline in neurological function, which could be due to increased intracranial pressure, bleeding, or other acute changes in the brain. This requires immediate assessment and intervention to prevent further deterioration.

Choice D Reason:

The client whose deep tendon reflexes have become hyperactive is showing signs of hyperreflexia. Hyperactive reflexes can indicate an upper motor neuron lesion, which affects the descending corticospinal tract. While this is a concerning sign that warrants further investigation, it is not as immediately critical as a sudden change in the GCS score.