The LPN creates a plan of care for a patient with Parkinson disease. The priority nursing diagnosis should be:
Risk for Falls related to unsteady gait.
Ineffective Self-Care Ability related to cognitive deficit.
Risk for Impaired Skin Integrity related to uncontrolled hand tremors.
Nutrition: Less Than Body Requirements related to frequent nausea during meals.
The Correct Answer is A
Choice A reason: Risk for Falls is the priority nursing diagnosis for a patient with Parkinson disease, as the disease affects the patient's balance, coordination, and posture. The patient may have difficulty walking, turning, and standing, which increases the risk of falling and injuring themselves. The nurse should implement interventions to prevent falls, such as providing assistive devices, removing environmental hazards, and educating the patient and family about fall prevention.
Choice B reason: Ineffective Self-Care Ability related to cognitive deficit is a possible nursing diagnosis for a patient with Parkinson disease, as the disease may impair the patient's memory, judgment, and problem-solving skills. The patient may have difficulty performing activities of daily living, such as bathing, dressing, and grooming. The nurse should assess the patient's self-care abilities, provide assistance as needed, and encourage the patient to maintain their independence and dignity.
Choice C reason: Risk for Impaired Skin Integrity related to uncontrolled hand tremors is another possible nursing diagnosis for a patient with Parkinson disease, as the disease causes involuntary movements of the hands, arms, and legs. The patient may scratch, rub, or injure their skin due to the tremors. The nurse should monitor the patient's skin condition, provide skin care, and protect the patient from skin breakdown.
Choice D reason: Nutrition: Less Than Body Requirements related to frequent nausea during meals is a potential nursing diagnosis for a patient with Parkinson disease, as the disease may affect the patient's appetite, digestion, and swallowing. The patient may experience nausea, vomiting, constipation, or dysphagia, which can lead to malnutrition and dehydration. The nurse should assess the patient's nutritional status, provide dietary modifications, and ensure adequate fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Presence of a synthetic silicone mesh stent in a coronary artery is not a contraindication for MRI. Silicone is a non-magnetic material that does not interfere with the magnetic field or cause any harm to the patient or the device.
Choice B reason: Allergy to shellfish and iodine is not a contraindication for MRI. Shellfish and iodine are not related to the contrast agent used for MRI, which is usually gadolinium. However, the patient should inform the provider if they have any history of allergic reactions to contrast agents or any other medications.
Choice C reason: Contact lenses are not a contraindication for MRI. Contact lenses are made of plastic or silicone, which are non-magnetic materials that do not interfere with the magnetic field or cause any harm to the patient or the device. However, the patient should remove them before the procedure to avoid any discomfort or irritation.
Choice D reason: Presence of an internal insulin pump in the abdomen is a contraindication for MRI. Insulin pumps are electronic devices that contain metal parts, batteries, and wires, which can be affected by the magnetic field and cause malfunction, damage, or injury to the patient or the device. Therefore, the patient should inform the provider and the MRI technician about the insulin pump and follow their instructions on how to manage it before, during, and after the procedure.
Correct Answer is A
Explanation
Choice A reason: Maintaining a flat lying position for 14 hours following the procedure is the highest priority teaching point for the patient who had a lumbar puncture. It helps to prevent cerebrospinal fluid leakage and post-lumbar puncture headache, which can be severe and debilitating.
Choice B reason: Muscular discomfort is expected after being in a curled position for a period of time, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, massage, or heat therapy.
Choice C reason: Resuming oral intake immediately after the procedure is not a priority teaching point for the patient who had a lumbar puncture. It is not contraindicated, but it is not essential either. The patient should drink plenty of fluids to replenish the cerebrospinal fluid and prevent dehydration.
Choice D reason: Mild pain is expected at the needle insertion site, but it is not the highest priority teaching point for the patient who had a lumbar puncture. It is a common and mild side effect that can be relieved by analgesics, ice packs, or dressing.
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