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: 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.
Correct Answer is C
Explanation
Choice A reason: Relaxing in a hot bath before bedtime is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Heat can worsen the symptoms of multiple sclerosis, such as muscle weakness, numbness, and vision problems. Therefore, the patient should avoid hot baths, showers, or saunas, and use cool compresses or fans to lower their body temperature.
Choice B reason: Performing deep breathing exercises every two hours is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Deep breathing can help reduce stress and anxiety, but it does not address the underlying causes of fatigue, such as inflammation, nerve damage, or sleep problems. Therefore, the patient should consult their doctor for appropriate treatment options and medication adjustments.
Choice C reason: Scheduling short periods of rest throughout the day is the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Fatigue is a common and disabling symptom of multiple sclerosis, which can affect the patient's daily activities and quality of life. Therefore, the patient should plan their tasks according to their energy level, prioritize the most important ones, and take frequent breaks to conserve their energy and prevent exhaustion.
Choice D reason: Including daily multivitamins in your diet is not the best suggestion to help decrease fatigue for a patient with multiple sclerosis. Multivitamins can provide some nutritional benefits, but they are not a substitute for a balanced and healthy diet. Therefore, the patient should eat a variety of foods, such as fruits, vegetables, whole grains, lean proteins, and low-fat dairy, and avoid processed, fried, or sugary foods that can increase inflammation and fatigue.
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