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 A
Explanation
Choice A reason: Patient should increase daily iron supplements, is a statement that indicates a need for additional teaching. Iron supplements are not recommended for patients with beta-thalassemia, because they already have high levels of iron in their blood due to the frequent blood transfusions. Excess iron can cause damage to the liver, heart, and other organs. Therefore, the patient should avoid iron supplements and foods rich in iron, and take chelation therapy to remove the excess iron from the body.
Choice B reason: Signs and symptoms of infection, is a statement that does not indicate a need for additional teaching. Patients with beta-thalassemia are at risk of developing infections, due to the impaired immune system and the exposure to blood-borne pathogens. Therefore, the patient should be aware of the signs and symptoms of infection, such as fever, chills, sore throat, cough, or skin lesions, and seek medical attention promptly.
Choice C reason: Our child will need to have blood transfusions, is a statement that does not indicate a need for additional teaching. Blood transfusions are the main treatment for patients with beta-thalassemia, because they help to increase the level of hemoglobin and red blood cells, and prevent anemia and its complications. Therefore, the patient should receive regular blood transfusions, usually every two to four weeks, depending on the severity of the condition.
Choice D reason: Swimming is a good activity for our child, is a statement that does not indicate a need for additional teaching. Swimming is a good activity for patients with beta-thalassemia, because it helps to improve the cardiovascular fitness, muscle strength, and joint mobility, and reduce the stress and fatigue. Therefore, the patient should engage in moderate physical activities, such as swimming, walking, or cycling, as tolerated, and avoid strenuous or competitive sports that can cause injury or dehydration.
Correct Answer is B
Explanation
Choice A reason: This is incorrect. After the age of 60, the plasma volume decreases and there is a decreased ability to fight infections. The decrease in plasma volume reduces the blood flow and oxygen delivery to the tissues, which impairs the immune function.
Choice B reason: This is correct. Healthy bone marrow function decreases with aging, which lowers the immune response to infection. The bone marrow produces fewer white blood cells, which are essential for fighting infections. The older adult also has a reduced response to vaccines, which makes them more susceptible to infections.
Choice C reason: This is incorrect. Older adults have an underactive antibody response to vaccines. This means that they do not produce enough antibodies to protect themselves from the pathogens that the vaccine is supposed to prevent.
Choice D reason: This is incorrect. An older person's blood is more prone to clotting, but this does not affect the infection-fighting cells. The infection-fighting cells can still travel through the blood vessels and reach the source of infection. However, the increased risk of clotting can lead to other complications such as stroke or heart attack.
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