The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

Place protective padding between the client and bed rails.

Provide privacy for the client during the event.

Observe the client's behavior during the event.

Record the client's level of consciousness after the event.

Answer and Explanation

The Correct Answer is A

A.   Placing protective padding between the client and bed rails is a safety measure to prevent injury during a seizure. This action helps protect the client from head or body trauma if they hit the bed rails or any surrounding surfaces during the seizure.
B.   Providing privacy is important for maintaining the client’s dignity during a seizure, but it is not the most immediate concern. The primary focus during a seizure should be on ensuring the client’s safety and monitoring the event. Privacy can be considered once the immediate safety and medical needs are addressed.
C.   Observing the client's behavior during the seizure is essential for documentation and subsequent medical evaluation. It helps in identifying the type, duration, and characteristics of the seizure, which is crucial for diagnosis and treatment. However, observation alone does not address immediate safety needs or interventions required during the seizure.
D.   Recording the client's level of consciousness after the seizure is important for assessing the postictal state and the extent of recovery. This information is valuable for understanding the impact of the seizure and guiding further medical care. However, during the seizure, immediate actions should focus on ensuring safety and managing the seizure itself.

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Correct Answer is B

Explanation

A. While assessing cognition is important for understanding the client’s overall functioning, the immediate issue of "freezing" during ambulation is more related to motor symptoms rather than cognitive impairment. "Freezing" in Parkinson's disease is a common motor symptom where the client feels as if their feet are glued to the floor.
B. The technique of pretending to step over an imaginary object (like a crack) is known to be a helpful strategy for managing "freezing" in Parkinson's disease. This technique provides a cognitive cue that can help the client initiate movement and overcome the freezing episodes. Confirming that this is an effective technique acknowledges the client's strategy and supports their efforts to improve mobility.

C. Reorienting the client to their location and circumstances can be helpful in situations where confusion or disorientation is an issue. However, in the case of "freezing" during ambulation, this response does not directly address the motor symptoms associated with Parkinson's disease. The problem here is more about movement initiation rather than orientation.
D. Moving to a carpeted area might help with traction and reduce the risk of slipping, but it does not directly address the issue of "freezing" episodes. The freezing phenomenon in Parkinson's disease is related to motor control rather than the type of flooring. While providing a safer walking environment is beneficial, it doesn’t target the underlying motor symptoms as directly as addressing the client’s technique.

A. Hematocrit of 33% (0.33 volume fraction). B. White blood cell count of 1,500/mm3 (1.5 x 10°) C. Hemoglobin of 10 g/dl (6.21 mmol/L) D. Red blood cell count of 3.5 x 10l(3.5 x 10").

Correct Answer is B

Explanation

A. Hematocrit measures the proportion of blood volume that is occupied by red blood cells. A hematocrit of 33% is lower than the normal range (42% to 52% for males and 37% to 47% for females). While this indicates anemia and reduced oxygen-carrying capacity of the blood, it is not directly related to the risk for infection.
B. White blood cells (WBCs) are crucial for the immune system and fighting infections. A WBC count of 1,500/mm³ is significantly below the normal range (5,000 to 10,000/mm³). This low WBC count, also known as leukopenia, indicates a decreased ability to fight infections, making the client highly susceptible to infections.
C. Hemoglobin measures the oxygen-carrying capacity of red blood cells. A hemoglobin level of 10 g/dL is below the normal range (14 to 18 g/dL), indicating anemia. While anemia affects overall health and can contribute to fatigue and weakness, it does not directly indicate the risk for infection.
D. The red blood cell (RBC) count measures the number of red blood cells in the blood. A count of 3.5 x 10^12/L is below the normal range (4.2 to 5.4 x 10^12/L), indicating a reduction in red blood cells and anemia. Like low hemoglobin, this value indicates anemia but does not directly reflect the risk for infection.

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The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assists a client with Parkinson's disease (PD) 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?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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