The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?
Plan to assess the client's cognition after returning to the room.
Confirm that this is an effective technique to help with ambulation.
Assist the client to a carpeted area to walk more easily.
Reorient the client to the present location and circumstances.
The Correct Answer is B
A. Assessing the client's cognition may be appropriate if there are concerns about cognitive function, but in this scenario, the client's response indicates a coping mechanism for freezing episodes rather than cognitive impairment.
B. Confirming that the client's technique of pretending to step over a crack is an effective strategy acknowledges the client's self-initiated coping mechanism for freezing episodes, which can help promote independence in ambulation.
C. Assisting the client to a carpeted area may help reduce the risk of falls but does not directly address the freezing episode or the client's coping strategy.
D. Reorienting the client to the present location and circumstances is unnecessary as the client's response indicates a conscious coping strategy rather than confusion or disorientation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Muscle atrophy may indicate various underlying conditions but is not typically associated with an exacerbation of SLE. While it should be noted, it is not the most critical finding to report in this context.
B. Low-grade fever is a common symptom of SLE exacerbation and may not require immediate reporting unless accompanied by other concerning symptoms.
C. Joint pain is a hallmark symptom of SLE exacerbation but may not warrant immediate reporting unless it is severe or debilitating.
D. Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.
Correct Answer is D
Explanation
A. Eating a bland diet and avoiding spicy foods are not specific recommendations for diverticulosis management. They may be applicable for other gastrointestinal conditions.
B. Having small frequent meals and sitting up after meals are general dietary recommendations for digestive health but are not specific to diverticulosis management.
C. Eating a soft diet with increased intake of milk and milk products may not be suitable for diverticulosis management, especially if lactose intolerance is present. Additionally, a soft diet may lack sufficient fiber.
D. Eating a high-fiber diet and increasing fluid intake are key recommendations for managing diverticulosis. High-fiber foods help promote regular bowel movements and prevent constipation, which can exacerbate diverticulosis.
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