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: 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: A

Rationale: The correct answer is A: Post-trauma syndrome related to being attacked. This diagnosis accurately reflects the client's symptoms of reliving the traumatic event, crying uncontrollably, and expressing fear. Post-trauma syndrome encompasses a range of symptoms following a traumatic event, such as flashbacks, anxiety, and emotional distress. The other choices are incorrect because they are either too vague (B: Psychological overreaction) or do not capture the specific nature of the client's symptoms (C: Needs assistance coping; D: Mental distress). Therefore, option A is the most appropriate diagnosis based on the client's presentation.

Correct Answer: B

Rationale: The correct answer is B: Do not stop medication abruptly. Abruptly stopping propranolol can lead to rebound hypertension and potentially life-threatening complications. The nurse should emphasize the importance of gradual tapering under medical supervision to avoid adverse effects. A: Having potassium levels checked is not directly related to propranolol use for hypertension management. C: Changes in appetite are not specific to propranolol use and may not be a significant concern compared to abrupt cessation of the medication. D: Resuming usual daily activities is important but not as crucial as the correct instruction to avoid abrupt discontinuation of propranolol.

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: Autoimmune reaction. Guillain-Barre Syndrome is an autoimmune disorder where the immune system mistakenly attacks the peripheral nerves, leading to muscle weakness and paralysis. This is supported by the patient's presentation of weakness in the legs. Bacterial infection (A) can trigger Guillain-Barre Syndrome, but it is not the root cause. High-fat diet (B) and heredity (C) are not associated with the development of this syndrome. In summary, autoimmune reaction is the primary mechanism underlying Guillain-Barre Syndrome, resulting in the patient's muscle weakness and inability to walk.

Correct Answer: D

Rationale: The correct answer is D. This intervention is appropriate because it addresses the patient's reduced muscle strength following a left-sided stroke and the risk for falling. Assisting the patient into and out of bed regularly helps prevent falls by ensuring safe mobility and reducing the likelihood of accidents. It promotes independence while also providing necessary support. A: Keeping all side rails down at all times may increase the risk of falls as it removes a safety measure that can help prevent falls. B: Encouraging the patient to remain in bed most of the shift can lead to deconditioning and muscle weakness, increasing the risk of falls. C: Placing the patient in a room away from the nurses' station does not directly address the risk for falls and may hinder timely assistance in case of emergencies. In summary, option D is the most appropriate intervention as it addresses the patient's needs, promotes safety, and supports mobility to prevent falls effectively.

Correct Answer: A

Rationale: The correct answer is A because after a total thyroidectomy, the client will no longer produce thyroid hormones, necessitating lifelong replacement therapy. This statement shows an understanding of the need for ongoing medication to maintain thyroid function. Choice B is incorrect as the client had a total thyroidectomy, so there is no risk of hyperthyroidism recurrence. Choice C is incorrect as the client will need ongoing care and monitoring for thyroid function. Choice D is incorrect as increasing caloric intake is not a necessary long-term care measure after a thyroidectomy.

Correct Answer: C

Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is important because the patient may not accurately express their pain level verbally. By addressing the discrepancy between the patient's verbal report and non-verbal cues, the nurse can gather more information to assess the patient's pain accurately. By directly communicating with the patient, the nurse can ensure that the appropriate interventions are provided. Choice A is incorrect because it disregards the need to address the patient's pain assessment. Choice B assumes the patient's preference without further clarification. Choice D jumps to administering pain medication without fully assessing the situation, which could lead to inappropriate treatment.