Which nursing interventions can help prevent falls in a patient with Parkinson’s disease? Choose all answers that are correct. i.Keep the patient’s call light within reach ii.Apply a soft vest restraint when the patient is in bed iii.Avoid use of throw rugs iv.Maintain the patient’s bed in a low position v.Encourage the patient to be independent for as long as possible vi.Provide a cane or walker for ambulation

Correct Answer: A

Rationale: The correct answers are i. Keep the patient’s call light within reach, iii. Avoid use of throw rugs, and iv. Maintain the patient’s bed in a low position. 1. Keeping the call light within reach ensures the patient can easily call for assistance, reducing the risk of falls. 2. Avoiding throw rugs prevents tripping hazards that can lead to falls. 3. Maintaining the bed in a low position reduces the risk of injury if the patient falls out of bed. The incorrect choices: - Choice B includes answer 3 (Avoid use of throw rugs), which is correct, but also includes answer 6 (Provide a cane or walker for ambulation), which is not specific to fall prevention. - Choice C includes answer 2 (Apply a soft vest restraint when the patient is in bed), which can increase the risk of falls due to restricted movement. - Choice D includes answers that are not directly related to fall prevention, such as 2 (Apply a soft vest

Correct Answer: D

Rationale: The correct answer is D. Asking about seeing halos around lights is relevant to assessing the patient's eye health as it could indicate conditions like glaucoma or cataracts. Upper respiratory infections (A), riding in a car (B), and scuba diving (C) are not directly related to eye health assessment. By focusing on symptoms directly related to the eyes, the nurse can gather relevant information for a more accurate assessment.

Correct Answer: C

Rationale: The correct answer is C: Developing nursing diagnoses before completing the database. This is incorrect because developing nursing diagnoses should be based on a comprehensive assessment and analysis of the patient's data. By developing nursing diagnoses before completing the database, the new nurse may overlook important information that could impact the accuracy of the diagnosis and subsequent care plan. Choice A (intravenous antibiotics) is incorrect because assigning a nursing diagnosis of Risk for infection for a patient on IV antibiotics is a common and appropriate practice given the increased risk of infection associated with invasive procedures. Choice B (Completing an interview and physical examination before adding a nursing diagnosis) is incorrect because nursing diagnoses should be developed based on the data collected during the assessment process, which includes the interview and physical examination. It is not necessary to complete the entire assessment before assigning a nursing diagnosis. Choice D (Including cultural and religious preferences in the database) is incorrect because while it is important to consider cultural and religious preferences in care planning, this does not directly relate to the

Correct Answer: A

Rationale: The correct answer is A: Naturally acquired passive immunity. This type of immunity occurs when antibodies are passed from mother to baby through the placenta or breast milk, providing temporary protection. The baby does not produce its antibodies, hence it is passive. Choice B, naturally acquired active immunity, involves the body producing its antibodies after exposure to a pathogen. Choice C, artificially acquired passive immunity, involves receiving preformed antibodies from an external source. Choice D, artificially acquired active immunity, involves the body producing antibodies in response to vaccination.

Correct Answer: D

Rationale: The correct answer is D because a brain abscess can be caused by direct invasion of the brain, spread of infection by other organs, and spread of infection from nearby sites. Direct invasion can occur from trauma or surgery, while infections from other organs like the lungs or heart can travel through the bloodstream to the brain. Infections from nearby sites such as the sinuses or ears can also spread to the brain. Therefore, all of these mechanisms can lead to the formation of a brain abscess. Choices A, B, and C alone do not encompass all the possible causes of a brain abscess, making D the correct comprehensive answer.

Correct Answer: B

Rationale: The correct answer is B: Make recommendations for revising the plan of care. When client outcomes are not met within the specified time frame, the nurse should reassess the plan of care to identify any potential reasons for the lack of progress. By making recommendations for revising the plan of care, the nurse can adjust interventions to better align with the client's needs and facilitate goal achievement. Continuing to follow the written plan of care (choice A) without modification may not address the underlying issues preventing goal attainment. Asking another health care professional to design a plan of care (choice C) may not be necessary if the nurse can assess and revise the current plan. Stating 'goal will be met at a later date' (choice D) does not address the need for immediate action to reassess and modify the plan for better outcomes.

Correct Answer: D

Rationale: The correct answer is D: Fever. Following splenectomy, patients are at risk for OPSI due to impaired immune response. Fever is a key symptom of infection and should alert the nurse to this possibility. Bruising around the operative site (A) is expected post-surgery. Pain (B) is common after surgery and may not specifically indicate OPSI. Irritability (C) is a vague symptom and not specific to OPSI. In summary, fever is the most concerning symptom as it can indicate an underlying infection in a postsplenectomy patient.

Correct Answer: B

Rationale: The correct answer is B: Use a low-pitched voice. This is because elderly individuals may have age-related hearing loss, making it difficult for them to hear higher frequencies. Using a low-pitched voice can help ensure that the client can hear and understand the nurse clearly. A: Leaning and shouting at the ear of the client may come across as aggressive and disrespectful. C: Opening the mouth wide while talking is not necessary and may be seen as patronizing. D: Using a medium-pitched voice may still be too difficult for the elderly client to hear clearly due to age-related hearing loss.

Correct Answer: A

Rationale: The correct answer is A because the drug should be resumed when the WBC count falls to 5,000mm3 to ensure the client's safety and efficacy of treatment. This criterion indicates that the client's immune system has recovered sufficiently to tolerate the drug. Choices B, C, and D are incorrect because they do not directly correlate with the client's immune system recovery, which is crucial for drug tolerance. Choice B focuses on the rise in WBC count, not the fall to a specific level. Choice C is related to a cosmetic side effect, not clinical readiness. Choice D is unrelated to immune system recovery.