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: This is incorrect. Generalized muscle weakness and severe muscle spasms are not late manifestations of amyotrophic lateral sclerosis, but rather early or intermediate symptoms. Amyotrophic lateral sclerosis is a progressive neurodegenerative disorder that affects the motor neurons that control voluntary muscles. The disease causes muscle weakness, stiffness, twitching, and cramps.
Choice B reason: This is incorrect. Mental confusion and aggressive behaviors are not common manifestations of amyotrophic lateral sclerosis, but rather signs of dementia or other psychiatric disorders. Amyotrophic lateral sclerosis does not usually affect the cognitive or emotional functions of the brain, except in some rare cases.
Choice C reason: This is incorrect. Dysarthria and decreased clarity of spoken words are not late manifestations of amyotrophic lateral sclerosis, but rather intermediate or advanced symptoms. Dysarthria is a speech disorder that results from the weakness or paralysis of the muscles involved in speech production. It causes slurred, slow, or distorted speech.
Choice D reason: This is correct. Impairment of respiratory muscles and cognition remains intact are common late manifestations of amyotrophic lateral sclerosis. As the disease progresses, the respiratory muscles become weak and unable to support breathing. This can lead to respiratory failure and death. However, the cognition of the patient usually remains intact until the end, as the disease does not affect the higher functions of the brain.
Correct Answer is A
Explanation
Choice A reason: This is correct. A white blood cell count of 1000/mm3 indicates severe neutropenia, which is a condition of having abnormally low levels of neutrophils, a type of white blood cell that fights infections. Neutropenic precautions are measures to protect the client from exposure to pathogens, such as wearing a mask, gloves, and gown, avoiding contact with sick people, and practicing good hygiene.
Choice B reason: This is incorrect. A red blood cell count of 5 million/mm3 is within the normal range for both males and females. It does not indicate any risk of infection or bleeding.
Choice C reason: This is incorrect. A clotting time of 10 minutes is also within the normal range, which is 8 to 15 minutes. It does not indicate any risk of infection or bleeding.
Choice D reason: This is incorrect. A thrombocyte count of 90,000 cells/mm3 is low, but not low enough to require neutropenic precautions. Thrombocytes, also known as platelets, are responsible for blood clotting. A low thrombocyte count increases the risk of bleeding, but not infection. The normal range for thrombocyte count is 150,000 to 450,000 cells/mm3.
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