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.
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Related Questions
Correct Answer is D
Explanation
A. Increasing anxiety may require intervention, but it does not pose an immediate threat to the client's health compared to other options.
B. Inappropriate laughter could indicate emotional lability, a common symptom in ALS, but it does not typically require immediate intervention unless it's accompanied by other concerning symptoms.
C. Asymmetrical weakness is common in ALS but may not necessarily warrant immediate intervention unless it is significantly affecting the client's ability to perform essential functions.
D. Weakened cough effort is a critical finding in a client with ALS, as it can lead to ineffective airway clearance and increase the risk of aspiration pneumonia. Immediate intervention, such as suctioning or respiratory support, may be necessary to maintain airway patency and prevent complications.
Correct Answer is A
Explanation
A. Crohn's disease with colectomy. Peritoneal dialysis involves instilling dialysis fluid into the peritoneal cavity, and conditions that affect the integrity or function of the peritoneum, such as Crohn's disease with colectomy, can be contraindications due to the risk of infection or inadequate dialysis.
B. Latent hepatitis C is not a contraindication for peritoneal dialysis, although active hepatitis C infection may be a concern due to increased risk of peritonitis.
C. Type 2 diabetes mellitus is not a contraindication for peritoneal dialysis; in fact, it is a common cause of end-stage renal disease and may necessitate dialysis.
D. Nephrotic syndrome history is not a contraindication for peritoneal dialysis; in fact, peritoneal dialysis may be indicated in some cases of renal failure associated with nephrotic syndrome.
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