Choice A reason: A soft diet with thin liquids may be recommended for patients with Parkinson's disease who have difficulty swallowing (dysphagia), but it is not the most appropriate intervention for all patients. Dysphagia is common in Parkinson's disease due to impaired muscle movement, and a soft diet can help prevent choking and aspiration.

Choice B reason: Assessing for orthostatic hypotension is crucial in the care of patients with Parkinson's disease. Orthostatic hypotension is a common non-motor symptom where there is a significant drop in blood pressure upon standing. Normal blood pressure should not drop more than 20 mm Hg systolic or 10 mm Hg diastolic within 2 to 5 minutes of standing. This condition can increase the risk of falls, which is a significant concern in this population.

Choice C reason: Exophthalmos, the bulging of the eyes, is not associated with Parkinson's disease. It is typically related to thyroid eye disease, such as Graves' disease, and would not be a relevant assessment for a Parkinson's patient unless there is a known co-existing thyroid condition.

Choice D reason: Limiting fluids to prevent urinary incontinence is not an appropriate intervention for Parkinson's disease. Adequate hydration is essential, and urinary incontinence should be managed with other strategies, such as bladder training, scheduled toileting, and possibly medication, depending on the cause.

Choice A reason: The serum lactate level of 3.9 mmol/L is significantly higher than the normal range of 0.5-2 mmol/L. This is a critical value to report as it indicates a high likelihood of sepsis, which is a life-threatening condition requiring immediate intervention. Elevated lactate levels suggest that the tissues are not adequately oxygenated, a state known as tissue hypoxia, which is a hallmark of sepsis.

Choice B reason: While the vital signs show a slight fever (100°F), the heart rate, respiratory rate, and blood pressure are within normal limits for an adult and do not indicate an immediate life-threatening condition.

Choice C reason: A pulse oximetry reading of 96% on supplemental oxygen is within the acceptable range, indicating adequate oxygen saturation and not a direct sign of sepsis.

Choice D reason: The presence of rhonchi bilaterally suggests airway obstruction due to mucus, which can be associated with pneumonia. However, this finding alone does not carry the same immediate risk of morbidity and mortality as an elevated lactate level indicative of sepsis.

Choice A reason: Levodopa/carbidopa therapy is often recommended to be taken with food to prevent nausea, which is a common side effect. Therefore, advising not to take it with food is incorrect.

Choice B reason: While levodopa/carbidopa can cause insomnia, it is not the most critical piece of information for discharge teaching. Managing insomnia can be part of ongoing treatment discussions.

Choice C reason: Checking for signs of infection is a general safety measure but is not specific to levodopa/carbidopa therapy. It is important for all medications and health conditions.

Choice D reason: It is crucial to take levodopa/carbidopa at the same time each day to maintain steady levels of the medication in the body, which helps to control the symptoms of Parkinson's disease effectively. Consistency in medication timing is key to managing the disease's symptoms.

Choice A reason: Tachycardia and weight gain are not typically associated with low T4 levels. Tachycardia and weight loss are more commonly seen in hyperthyroidism, where T4 levels would be elevated.

Choice B reason: Diarrhea and hypoglycemia are not directly related to low T4 levels. Diarrhea can be a symptom of hyperthyroidism, while hypoglycemia is not commonly associated with thyroid function.

Choice C reason: Hypotension and periorbital edema are findings that can be associated with hypothyroidism, which is consistent with the low T4 level of 2.9 mcg/dL. Hypothyroidism can lead to reduced cardiac output and systemic vascular resistance, causing hypotension. Periorbital edema is also a common sign of hypothyroidism due to mucopolysaccharide deposition in the skin.

Choice D reason: Tremors and dyskinesias are more commonly associated with hyperthyroidism, not hypothyroidism. Elevated levels of thyroid hormones can lead to these neurological symptoms.

Choice A reason: Petechiae are small red or purple spots caused by bleeding into the skin, typically associated with platelet disorders, and are not a direct indicator of SBP.

Choice B reason: Increased abdominal pain is a common symptom of SBP, as the condition causes inflammation and irritation of the peritoneum, which can lead to significant discomfort.

Choice C reason: Jaundice is a sign of liver dysfunction but is not specific to SBP. It results from high levels of bilirubin in the blood and can occur in various liver diseases.

Choice D reason: Blood in emesis (vomiting) may indicate gastrointestinal bleeding, which can be a complication of cirrhosis but is not specific to SBP.

Choice A reason: In sepsis, inflammatory mediators cause vasodilation and increased capillary permeability, leading to fluid leaking out of the vascular space, resulting in hypotension.

Choice B reason: Platelet aggregation and thrombus formation can occur in sepsis but are more related to disseminated intravascular coagulation (DIC) rather than directly causing hypotension.

Choice C reason: Decreased blood glucose and oliguria can be consequences of sepsis but are not the primary pathophysiological processes responsible for hypotension.

Choice D reason: Hypoxemia and anaerobic metabolism may result from the effects of sepsis on the body, including hypotension, but they are not the direct cause of hypotension.

Choice A reason: Assessing for hematuria is important but not the priority action. Hematuria can be a symptom of various conditions and does not directly address the abnormal laboratory results.

Choice B reason: Monitoring temperature is a routine action in sepsis management but does not address the immediate concern of the abnormal laboratory results, specifically the elevated aPTT and low platelet count.

Choice C reason: Evaluating skin turgor is a method to assess dehydration, which is not the immediate concern indicated by the laboratory results.

Choice D reason: The elevated aPTT and low platelet count suggest a potential coagulopathy, which could be a sign of disseminated intravascular coagulation (DIC), a complication of sepsis. Administering heparin may be part of the treatment for DIC to prevent further clotting and is a priority action in this context.

Choice A reason: Less constipation is not a direct indicator of effective PTU therapy, as constipation can be associated with hypothyroidism, and PTU is used to treat hyperthyroidism.

Choice B reason: Weight loss is expected in hyperthyroidism, and PTU is used to reduce thyroid hormone levels, not to promote weight loss.

Choice C reason: A reduction in facial puffiness can indicate that the PTU is effectively reducing thyroid hormone levels, as puffiness can be associated with hyperthyroidism.

Choice D reason: Improvement in vision is not a typical outcome of PTU therapy and does not directly indicate its effectiveness.

Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.

Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.

Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.

Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.

Choice A reason: A temperature of 99.6°F is a mild fever and not specifically indicative of the late phase of septic shock.

Choice B reason: Skin that is flushed with a capillary refill of less than 3 seconds does not suggest the late phase of septic shock, which would typically present with poor perfusion.

Choice C reason: A renal output of 45 mL/hr is within the normal range (0.5-1 mL/kg/hr for adults) and does not necessarily indicate the late phase of septic shock.

Choice D reason: Arrhythmias can be a sign of the late phase of septic shock as they indicate cardiac dysfunction, which is a result of decreased tissue perfusion and can lead to multiple organ failure.

Choice A reason: While assessing temperature is important for monitoring infection, it is not the immediate priority in the treatment of UTI and sepsis.

Choice B reason: Monitoring urine output is crucial for a UTI but does not address the systemic infection that sepsis represents.

Choice C reason: Administering antibiotics is the most critical intervention for a client with sepsis due to a UTI, as it directly addresses the underlying infection and can be life-saving.

Choice D reason: Evaluating the current CBC is important for understanding the client's baseline and response to infection but is secondary to the administration of antibiotics.

Choice A reason: A pulse oximetry reading of 96% is within normal limits and does not indicate an ineffective response to the medications.

Choice B reason: A heart rate of 77, regular, is also within normal limits and does not suggest an ineffective response.

Choice C reason: Trace bilateral ankle edema may persist even after effective treatment due to residual effects of heart failure.

Choice D reason: A urine output of 60 mL over 2 hours post-diuretic administration suggests an inadequate response, as furosemide is expected to produce a significant diuresis to reduce fluid overload in acute heart failure.

Choice A reason: The statement about being able to sit down to put on pants and shoes indicates that the client is implementing safety measures to prevent falls, which is a positive outcome of effective teaching.

Choice B reason: Exercising daily and resting when tired is an appropriate strategy for managing Parkinson's disease symptoms, suggesting that the client has understood the education provided.

Choice C reason: The statement about not needing a walker could indicate a lack of understanding of the importance of mobility aids in preventing falls, which is a concern for clients with Parkinson's disease.

Choice D reason: Removing loose rugs from the house is a preventive measure to reduce fall risk, indicating that the client and family have understood and applied the education.

Choice A reason: Monitoring platelet count is important in sepsis as thrombocytopenia can occur due to disseminated intravascular coagulation (DIC).

Choice B reason: Urine specific gravity is not typically monitored for sepsis unless there is a concern for renal function or fluid balance.

Choice C reason: Lactate levels are monitored in sepsis to assess the severity of septic shock and tissue hypoperfusion.

Choice D reason: PaO2 is monitored to assess oxygenation status, which can be compromised in sepsis due to respiratory dysfunction.

Choice E reason: Serum ammonia is not typically monitored for sepsis unless there is a concern for hepatic function or encephalopathy.

Choice A reason: An oral temperature of 99.8°F (37.7°C) post-operatively may not be unusual and does not necessarily indicate a complication.

Choice B reason: A post-operative hemoglobin of 10.9 g/dL is slightly below the normal range but may be expected after surgery due to blood loss.

Choice C reason: A client reporting a pressure sensation at the incision site could indicate bleeding or swelling under the incision, which can be a sign of a hematoma, a serious complication that needs immediate attention.

Choice D reason: Pain at the incision site is expected post-operatively and can be managed with pain relief measures.

Choice A reason: A pH of 7.48 is above the normal range (7.35–7.45), indicating a state of alkalosis, not acidosis. A PaCO2 of 31 mm Hg is below the normal range (35–45 mm Hg), which could indicate respiratory alkalosis if it were the primary disorder. An HCO3 level of 26 mEq/L is within the normal range (22–26 mEq/L) and does not suggest metabolic acidosis. Therefore, this choice does not reflect the metabolic acidosis seen in diabetic ketoacidosis (DKA).

Choice B reason: A pH of 7.42 is within the normal range, and a PaCO2 of 39 mm Hg is also within the normal range, suggesting neither acidosis nor alkalosis. An HCO3 level of 25 mEq/L is within the normal range and does not indicate the metabolic acidosis characteristic of DKA. Thus, this choice does not match the expected ABG results for DKA.

Choice C reason: A pH of 7.34 is just below the normal range, indicating a slight acidosis1. A PaCO2 of 40 mm Hg is within the normal range, suggesting that the primary issue is not respiratory. An HCO3 level of 21 mEq/L is slightly below the normal range, which could suggest a mild metabolic acidosis. However, the changes are not as pronounced as typically seen in DKA, where more significant acidosis is expected.

Choice D reason: A pH of 7.17 is significantly below the normal range, indicating severe acidosis1. A PaCO2 of 69 mm Hg is well above the normal range, which would usually suggest respiratory acidosis. However, in the context of DKA, a compensatory respiratory alkalosis often occurs, and the elevated PaCO2 may indicate a mixed acid-base disorder. An HCO3 level of 25 mEq/L is within the normal range, but given the low pH, it suggests that the body has been compensating for an acid-base disturbance. This choice most closely aligns with the metabolic acidosis and the compensatory respiratory changes expected in DKA.

Choice A reason: A thyroidectomy, which is the surgical removal of the thyroid gland, directly leads to hypothyroidism because the body can no longer produce thyroid hormones. This client is at the greatest risk of developing hypothyroidism.

Choice B reason: While exposure to certain chemicals in pesticides can be a risk factor for thyroid dysfunction, it does not pose as immediate a risk as the removal of the thyroid gland itself.

Choice C reason: Thyroid nodules can be associated with thyroid dysfunction, but not all nodules result in hypothyroidism, and many are benign and asymptomatic.

Choice D reason: Vomiting secondary to influenza is not directly related to the development of hypothyroidism.

Choice A reason: Learning sign language can be beneficial but may not be practical or immediately helpful for the client and spouse dealing with communication issues due to PD.

Choice B reason: Exaggerating the pronunciation of words may help some clients with PD, but it can also be tiring and not effective for all, especially if the client has significant speech difficulties.

Choice C reason: Speaking in a louder tone of voice does not necessarily improve communication with a person who has PD, as the issue often lies with the client's ability to speak, not with hearing.

Choice D reason: Writing can be an effective way for clients with PD to communicate, especially if they have difficulty speaking or being understood. It allows for clear communication without the need for verbal articulation.

Choice A reason: This response acknowledges the patient's feelings and invites further discussion, which can help the nurse understand the patient's concerns and provide appropriate support.

Choice B reason: Asking about specific challenges can be helpful, but it might be too direct for an initial response when the patient is expressing a general sense of being overwhelmed.

Choice C reason: While it's true that the healthcare team will provide support, this response may not address the patient's immediate emotional needs and concerns.

Choice D reason: This response might seem dismissive of the patient's concerns and does not acknowledge the difficulty of adjusting to a chronic illness like Parkinson's disease.

Choice A reason: The ABG results show an elevated pH and HCO3, which are indicative of metabolic alkalosis. The PaCO2 is within the normal range, suggesting that it is uncompensated.

Choice B reason: Respiratory acidosis would be indicated by an elevated PaCO2 and a decreased pH, which is not the case here.

Choice C reason: Metabolic acidosis would be indicated by a decreased pH and HCO3, which is not consistent with the given results.

Choice D reason: Respiratory alkalosis would be indicated by a decreased PaCO2 and an increased pH, which is not consistent with the given results.

Choice A reason: While individuals with rheumatoid arthritis may have an increased risk of infection due to the disease itself or the use of immunosuppressive medications, it does not pose as high a risk as intravenous lines for sepsis.

Choice B reason: A peripherally inserted central catheter (PICC) line, especially when used for total parenteral nutrition (TPN), presents a significant risk for infection due to the direct access to the bloodstream, making this client at the highest risk for sepsis.

Choice C reason: Asthma and bronchitis can lead to respiratory infections, but these conditions do not typically result in sepsis unless the infection becomes severe and systemic
.

Choice D reason: Renal calculi (kidney stones) can cause infections; however, they are less likely to lead to sepsis compared to a central line.

Choice A reason: Sodium restriction is a standard intervention in the management of cirrhosis, particularly when there is fluid retention leading to a distended abdomen (ascites) and weight gain.

Choice B reason: Encouraging fluids would not be appropriate for a client with cirrhosis who is already experiencing fluid overload, as indicated by a distended abdomen and weight gain.

Choice C reason: Checking lipase levels is associated with pancreatic function and would not be a direct intervention based on the symptoms of cirrhosis presented.

Choice D reason: Pancrealipase is used to aid digestion in patients with pancreatic insufficiency and is not related to the management of cirrhosis symptoms such as ascites and dyspnea.

Choice A reason: The statement about the medication taking a few weeks to work fully is accurate and does not require follow-up.

Choice B reason: The statement that levothyroxine replaces the hormone the body used to produce is correct and reflects an understanding of the therapy.

Choice C reason: Acknowledging the possibility of lifelong medication is appropriate for levothyroxine therapy in the case of hypothyroidism.

Choice D reason: Levothyroxine should be taken on an empty stomach, typically 30 minutes to an hour before breakfast, to ensure proper absorption. This statement indicates a misunderstanding that requires nurse follow-up.

Choice A reason: Encouraging ambulation is not a priority during a thyroid storm, as it can exacerbate symptoms.

Choice B reason: Sending a urine sample for culture is not related to the immediate management of thyroid storm.

Choice C reason: Monitoring temperature is crucial in the management of thyroid storm, as hyperthermia is a common and serious symptom.

Choice D reason: Administering levothyroxine during a thyroid storm would be contraindicated, as it could worsen the condition.

Choice A reason: Prolonged vomiting typically leads to metabolic alkalosis due to the loss of gastric acid, which is not consistent with the ABG results showing acidosis.

Choice B reason: COPD can lead to respiratory acidosis, as indicated by the elevated PaCO2 and low pH in the ABG results, making it a likely contributor to these findings.

Choice C reason: Chronic renal failure can lead to metabolic acidosis, but the HCO3 level is within the normal range, which does not support this as the primary condition.

Choice D reason: Anxiety and hyperventilation usually result in respiratory alkalosis due to the excessive exhalation of CO2, which is the opposite of what the ABG results show.