To achieve the outcome of fall prevention at home in the client diagnosed with Parkinson's Disease (PD), which intervention would the nurse include in the plan of care?

Arrange for social service consult for assistance with medication purchase

Have the client seen by a nursing assistant 3 times a week for hygiene

Ensure adequate lighting in areas where the client will ambulate

Reter the client to a nutritionist to address dietary measures

Answer and Explanation

The Correct Answer is C

A) Arrange for social service consult for assistance with medication purchase:
While arranging for social service support can be beneficial in ensuring the client has access to necessary medications, this is not directly related to fall prevention at home. Falls in Parkinson's disease are more closely associated with mobility, balance, and environmental factors, which should be the focus of interventions aimed at reducing fall risk. Medication access is important but secondary to safety measures related to physical environment and mobility.

B) Have the client seen by a nursing assistant 3 times a week for hygiene:
While assistance with hygiene can certainly help support the client’s daily needs, the frequency of visits for hygiene care alone does not specifically address fall prevention. Falls are more directly linked to issues such as impaired balance, freezing episodes, and poor mobility—issues that should be addressed through environmental modifications and specific interventions aimed at improving safety during ambulation and transfers.

C) Ensure adequate lighting in areas where the client will ambulate:
Ensuring adequate lighting in areas where the client will ambulate is a critical intervention for fall prevention in individuals with Parkinson's disease. Parkinson's disease often causes balance and coordination problems, and inadequate lighting can increase the risk of tripping or falling, especially at night or in poorly lit areas. Proper lighting helps the client see obstacles and navigate their environment safely. This intervention directly addresses a key factor in fall risk and is an important part of the plan of care.

D) Refer the client to a nutritionist to address dietary measures:
Referral to a nutritionist can be helpful in managing some aspects of Parkinson's disease, particularly for addressing issues like constipation, weight management, or dysphagia. However, dietary measures do not have a direct impact on fall prevention. Fall prevention should focus more on mobility, strength, environmental safety, and managing the symptoms of Parkinson's disease that affect balance and movement.

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Correct Answer is B

Explanation

A. and record vital signs every 4 hours:
While vital signs are important, monitoring every 4 hours may not be frequent enough in an intensive care setting, especially for a client requiring mechanical ventilation. Vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, should be monitored more frequently (at least every hour) to detect changes in the patient's condition, particularly since positive pressure ventilation can significantly affect circulatory status.

B. Intake and output hourly:
In acute respiratory distress syndrome (ARDS), the client may require mechanical ventilation to support breathing. Positive pressure ventilation, while essential for improving oxygenation, can increase intrathoracic pressure, which may impair venous return to the heart, decreasing cardiac output. As a result, it is critical to monitor the fluid balance closely, as fluid overload can worsen the patient's condition and contribute to pulmonary edema or other complications. Hourly assessment of intake and output (I&O) helps the nurse monitor renal function, fluid status, and cardiac output. Maintaining a proper balance of fluids is crucial in managing ARDS and its associated complications.

C. Heart and lung sounds every shift:
A shift assessment of heart and lung sounds is useful but is not frequent enough to detect early changes in a client with decreased cardiac output or other complications related to mechanical ventilation. More frequent monitoring of lung sounds and heart function may be necessary, particularly in clients at risk of ventilator-associated complications like ventilator-associated pneumonia (VAP), pulmonary edema, or arrhythmias.

D. Level of consciousness every shift:
Monitoring level of consciousness is important, especially in clients with ARDS and mechanical ventilation, as changes in consciousness can indicate worsening hypoxia or hypercapnia. However, this assessment is less directly related to the immediate concern of decreased cardiac output, which can be more effectively managed through continuous monitoring of fluid status and vital signs rather than consciousness alone. Though consciousness should be monitored regularly, I&O hourly would be more crucial in this context for managing cardiac output.

A. pH 7.33, PaCO2 35 mmHg, Pa02 78 mmHg, HCO3 20 mEq/L. B. heart rate 80 and respiratory rate 20. C. 02 saturation of at least 94%. D. sodium 135 mg/di. and potassium 4.8 mg/dL.

Correct Answer is C

Explanation

A. pH 7.33, PaCO2 35 mmHg, PaO2 78 mmHg, HCO3 20 mEq/L:
This answer choice indicates respiratory acidosis (pH < 7.35, low bicarbonate), but the goal in acute respiratory failure is not just to adjust the pH alone; the more immediate concern is correcting oxygenation. The PaO2 of 78 mmHg is below the normal range (80-100 mmHg), indicating hypoxemia that should be corrected first. The goal should be to improve PaO2 to acceptable levels (≥80 mmHg) and achieve adequate oxygen saturation. This ABG result does not fully align with the immediate goals of treatment.

B. Heart rate 80 and respiratory rate 20:
While normal vital signs like heart rate and respiratory rate are important, they are not the primary goal of treatment in acute respiratory failure. The focus during ventilator support is to improve oxygenation and ventilation rather than simply achieving normal heart and respiratory rates. In acute respiratory failure, abnormal heart and respiratory rates are often a result of hypoxia or hypercapnia (high CO2), so normalizing oxygenation and carbon dioxide levels is more critical initially.

C. O2 saturation of at least 94%:
The primary goal in acute respiratory failure is to maintain adequate oxygenation. In this context, the goal of ventilator support is to correct hypoxemia (low blood oxygen levels) and restore normal oxygen saturation. A target oxygen saturation of at least 94% is commonly considered appropriate for most patients in acute respiratory failure to ensure that tissues are receiving enough oxygen to prevent organ damage. This is a key aspect of managing respiratory failure and ensuring adequate tissue perfusion. Oxygen saturation below 90% is typically considered to indicate a severe level of hypoxemia, requiring prompt intervention.

D. Sodium 135 mg/dL and potassium 4.8 mg/dL:
While electrolyte levels are important to monitor in any critically ill patient, the main goal of treatment in acute respiratory failure is improving oxygenation and ventilation rather than focusing specifically on normalizing sodium or potassium levels. Correcting imbalances in electrolytes can be part of overall care, but it is not the primary objective in this situation. Oxygenation (as measured by PaO2 and O2 saturation) takes priority over correcting individual electrolytes.

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Arterial Blood Gases
pH	7.35-7.45
PaCO2	35-45mmHg
PaO2	80-100mmHg
HCO3-	22-26 mEq/L
O2 Saturation	>95%
Chemistry
BUN	8-21mg/dl
Creatinine	0.5-1.2mg/dl
Na	135-145 mEq/L
K	3.5-5.3 mEq/L
Cl	97-107 mEq/L
CO2	22-26 mEq/L
Ca	8.2-10.2 mg/dl
Glucose	65-99 mg/dl
Mg	1.7-2.2 mg/dl
PO4	2.5-4.5 mg/dl

To achieve the outcome of fall prevention at home in the client diagnosed with Parkinson's Disease (PD), which intervention would the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with acute respiratory distress syndrome (ARDS) who requires mechanical ventilation. A client problem of decreased cardiac output from the positive pressure ventilator has been identified. What should the nurse include in the plan of care? Assess:

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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