Nokea
Which of the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?
- A. Impaired Physical Mobility
- B. Dysreflexia
- C. Hypothermia
- D. Impaired Dentition
Correct Answer: A
Rationale: As Parkinson's disease progresses and complications develop, impaired physical mobility is a relevant nursing diagnosis due to symptoms like a shuffling gait and rigidity that can impair movement. Dysreflexia is not typically associated with Parkinson's disease; it is more commonly seen in spinal cord injuries. Hypothermia is a condition of low body temperature and is not directly related to Parkinson's disease progression. Impaired Dentition involves issues with teeth and oral health, which are not specific to Parkinson's disease complications.
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While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?
- A. Unplug the bed's power source.
- B. Remove the client from the bed immediately.
- C. Notify the biomedical department at once.
- D. Turn off the oxygen.
Correct Answer: A
Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.
The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate a need for teaching reinforcement?
- A. "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."?
- B. "I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding."?
- C. "I can clean around the tube with water and mild soap."?
- D. "I should avoid using Vaseline around the nostril and tube."?
Correct Answer: A
Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection. Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration. Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection. Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.
A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
- A. diced fruit
- B. apple juice with a liquid thickener
- C. Jell-O™
- D. toast
Correct Answer: B
Rationale: The correct choice is apple juice with a liquid thickener. A client with dysphagia is at risk for aspiration, so it is crucial to start with liquids and assess the client's ability to swallow before introducing solid foods. Using a liquid thickener with apple juice allows the healthcare provider to evaluate swallowing function. Jell-O™, although it melts into a clear liquid, should be avoided initially as it may not provide a clear assessment of swallowing ability. Diced fruit and toast are solid foods that should be introduced only after the client's swallowing ability with liquids has been assessed.
An LPN is caring for a primarily bedridden client. Which finding should be of least concern?
- A. swollen feet
- B. brown discoloration above the ankles
- C. leg pain
- D. capillary refill time of 3 seconds on the big toe
Correct Answer: D
Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.
A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?
- A. "You can receive a sedative to help you relax during the test."?
- B. "There is absolutely nothing to worry about."?
- C. "There is no discomfort with this test, so don't be anxious."?
- D. "The test won't last long, so you can handle it."?
Correct Answer: A
Rationale: The correct response acknowledges the client's anxiety and offers a practical solution to alleviate it, showing empathy and addressing the client's concerns. Offering a sedative to help relax during the test is a proactive approach to managing the client's anxiety. Choices B and C dismiss the client's feelings by invalidating their anxiety, which can further escalate their distress. Choice D downplays the client's feelings by implying they should not be worried, which does not effectively address the client's emotional state.