Prioritize the nursing interventions for Mr. Frank.
Options:
Teach the spouse how to assist with transfers and mobility.
Collaborate with physical therapy for gait training.
Monitor for dysphagia during meals.
Assess the patient's response to Carbidopa-Levodopa.
Encourage regular high-calorie, nutrient-dense snacks.
The Correct Answer is D
Choice A reason: Teaching the spouse how to assist with transfers and mobility is important for long-term care, but it is not the highest priority at this moment. The focus should be on immediate patient care and assessment.
Choice B reason: Collaborating with physical therapy for gait training is essential for improving the patient's mobility and safety, but it can be scheduled after addressing more urgent needs.
Choice C reason: Monitoring for dysphagia during meals is crucial to prevent aspiration, especially in patients with Parkinson's disease. However, this is a part of ongoing care and not necessarily the immediate priority unless the patient is actively eating.
Choice D reason: Assessing the patient's response to Carbidopa-Levodopa is the highest priority because it directly impacts the patient's overall symptom management. Effective control of Parkinson's symptoms can improve mobility, reduce rigidity, and decrease the risk of complications such as falls and dysphagia.
Choice E reason: Encouraging regular high-calorie, nutrient-dense snacks is important for maintaining the patient's nutritional status, but it is not the immediate priority in comparison to evaluating the effectiveness of medication management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Checking the blood pressure and pulse is important as part of the routine monitoring of vital signs to assess the patient's hemodynamic status. However, it is not the first action to take following a thyroidectomy. Ensuring that the patient's airway is clear and that there is no respiratory distress is paramount, as any compromise in the airway can lead to life-threatening situations. Blood pressure and pulse can be checked after confirming the patient is breathing properly.
Choice B reason: Observing the dressing for bleeding is also important because post-operative bleeding can be a serious concern. However, this action should follow the assessment of the patient's airway. If the patient is experiencing respiratory distress, addressing the airway takes precedence. Once it is confirmed that the airway is clear, then the nurse can check for bleeding and ensure the dressing is intact.
Choice C reason: Supporting the patient's head with pillows is beneficial for comfort and proper positioning, especially to avoid strain on the surgical site. However, positioning should not be the first priority. Ensuring that the patient's airway is clear and that there is no respiratory compromise is the most urgent concern. Proper positioning can be done after confirming that the patient is breathing adequately.
Choice D reason: Assessing the patient's respiratory effort is the first and most critical action. Following a thyroidectomy, there is a risk of respiratory complications due to potential swelling, bleeding, or damage to the trachea and surrounding structures. Immediate assessment of respiratory effort ensures that the airway is patent and the patient is not in respiratory distress. This step is crucial to prevent hypoxia and other serious complications.
Correct Answer is B
Explanation
Choice A reason: Reassessing vital signs in 1 hour is not an immediate action and does not address the patient’s current symptoms of dizziness and unsteady gait, which indicate a potential problem that requires immediate attention. Waiting an hour to reassess may delay necessary interventions that could prevent harm.
Choice B reason: Assisting the patient into a sitting position and notifying the healthcare provider is the most appropriate action. The symptoms of dizziness and unsteady gait, along with a BP of 98/60 mmHg, suggest that the patient may be experiencing orthostatic hypotension or a side effect of Carbidopa-Levodopa. Elevating the patient's position can help prevent falls, and notifying the healthcare provider ensures that the situation is assessed and managed promptly. This action addresses the immediate safety of the patient and facilitates appropriate medical intervention.
Choice C reason: Administering the next dose of Carbidopa-Levodopa early is not recommended without specific orders from the healthcare provider. It could potentially lead to overmedication and worsen the patient’s symptoms or cause adverse effects. Medication administration should always follow the prescribed schedule unless otherwise directed by the healthcare provider.
Choice D reason: Educating the patient about increasing his exercise is important for overall health and mobility but is not an immediate intervention for the acute symptoms of dizziness and unsteady gait. The patient’s current condition requires prompt assessment and intervention rather than education on exercise, which can be addressed later once the immediate issue is managed.
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