Which problem statement/nursing diagnosis is most appropriate for a person with Parkinson disease?
Risk for falls related to unsteady gait
Risk for impaired skin integrity related to tremor
Nutrition: less than body requirements related to nausea
Ineffective airway clearance related to drooling
The Correct Answer is A
A. Parkinson’s disease often causes motor symptoms such as rigidity and bradykinesia, leading to an unsteady gait and increased fall risk.
B. Tremors do not directly cause impaired skin integrity; immobility or pressure may be more relevant factors.
C. Nausea is not a primary symptom of Parkinson’s disease or its typical treatments.
D. Drooling occurs but is less immediately threatening than fall risk; ineffective airway clearance may develop but is not the most common nursing diagnosis early on.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. In Buck traction, the child’s heels should not be pressed against the foot of the bed, as this disrupts the traction forceand may lead to skin breakdown or impaired circulation. The body must remain in proper alignment, and the child should be positioned so that traction can pull effectively.
B. Elevating the head of the bed up to 20 degreesis acceptable to promote comfort and prevent respiratory complications without affecting traction.
C. Ropes must be aligned properly on pulleysto ensure smooth traction force. This is a correct observation.
D. Weights should hang freelyat all times to maintain consistent traction; this is the correct setup.
Correct Answer is A
Explanation
A. The nurse should assess for alteration in peripheral circulation, such as changes in color, temperature, pulse, or sensation in the lower extremities. The abductor wedgekeeps the legs abducted to prevent dislocation of the hip, but if applied improperly, it may impair circulation or cause nerve compression.
B. Muscle spasms can occur after surgery but are not directly related to the use of an abduction wedge.
C. Compression fractures are not a typical concern in the immediate care of a patient with an abduction wedge after hip replacement.
D. While correct wedge size is important, the priorityis to monitor for complications such as compromised circulation.
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