N4510 Parkinsonism
The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern?
2) Risk for injury related to gait disturbances. Rationale: The client with Parkinson disease may fall because of gait disturbances. Decreased mobility and impaired skin are problems but not the priority. Pain is usually not a manifestation of Parkinson disease.
Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment?
1) A raised toilet seat. Rationale: A raised toilet seat will reduce strain on the back muscles and make it easier for the client to rise from the seat without injury. The client is not bedridden and will not need side rails for the bed or a trapeze above the bed. Clients with Parkinson disease have poor balance and a propulsive gait, which makes it unsafe to use crutches.
When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client?
1) Avoid leaning forward. Rationale: The client with Parkinson disease often has a stooped posture [1] [2] [3] because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.
A client is admitted to the hospital with the diagnosis of Parkinson disease. What medication does the nurse expect the healthcare provider to prescribe to relieve the client's physiologic responses to this disease?
1) Carbidopa-levodopa Rationale: Levodopa crosses the blood-brain barrier and converts to dopamine, a substance depleted in Parkinson disease. Isocarboxazid is a monoamine oxidase inhibitor used for the treatment of psychological symptoms associated with severe depression, not physiologic symptoms of Parkinson disease. Dopamine is not given because it does not cross the blood-brain barrier. Pyridoxine can reverse the effects of some antiparkinsonian medications and is contraindicated.
A client residing in an assisted living facility is diagnosed with Parkinson disease, and the healthcare provider prescribes selegiline. What precaution will the nurse teach the client?
1) Change to a standing position slowly. Rationale: A common side effect of selegiline is dizziness. Safety precautions are necessary to prevent falls caused by orthostatic hypotension. Taking the medication with food or milk limits gastrointestinal irritation. Monitoring blood glucose levels is not necessary. Nausea is a common side effect of selegiline; the medication should not be withheld without the healthcare provider's supervision. Abrupt withdrawal may precipitate a parkinsonian crisis.
A nurse is assessing four clients with musculoskeletal disorders. Which client does the nurse suspect of having Parkinson disease?
1) Client A - Festinating gait, trunk and knee flexes when the body is rigid. Rationale: Festinating gait, when the neck, trunk, and knees flex when the body is rigid, in client A indicates Parkinson disease. A leg-length discrepancy of more than one inch due to arthritis or fracture may lead to the short-leg gait in client B. Neurogenic disorders such as cerebral palsy and hemiplegia may lead to the spastic gait in client C, which is manifested by jerky, uncoordinated, and cross-knee movement. Neurogenic disorders such as peroneal nerve injury and paralyzed dorsiflexor muscles may lead to the steppage gait in client D; this is manifested by increased hip and knee flexion to clear the foot from the floor and foot-dropping while walking.
A client is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical? Select all that apply.
1) Muscle rigidity 2) Blank facial expression Rationale: With Parkinson disease muscle rigidity occurs as a result of an imbalance between excitatory and inhibitory messages in the basal ganglia. With Parkinson disease there is a lack of neural control of fine-motor movements, resulting in a characteristic masklike face. Leaning toward an affected side is unrelated to Parkinson disease; this often is associated with a brain attack (CVA). Movement usually abolishes tremors; these are known as nonintention tremors. Hyperextension of the affected extremities does not occur with Parkinson disease; both arms fall rigidly to the sides and do not swing with a regular rhythm when walking, producing a shuffling gait.
A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply.
1) Nonintention tremors 3) Masklike facial expression 5) Rigidity to passive movement Rationale: Nonintention tremors associated with Parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. A masklike facial expression results from nigral and basal ganglial depletion of dopamine, an inhibitory neurotransmitter. Cogwheel rigidity is increased resistance to passive motion and is a classic sign of Parkinson. Constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. The tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglial control.
A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply.
1) Resting tremors 2) Flattened affect 5) Slow voluntary movements Rationale: Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.
An elderly adult with Parkinson's disease falls while going to the bathroom and gets injured. The nurse taking care of the client informs the primary healthcare provider. What step should the nurse take to alert the risk management system?
1) The nurse should document the incident in the occurrence report tool. Rationale: To alert the risk management system and to prevent the recurrence of such occurrences, the nurse should document the incident in the occurrence report tool. The nurse should provide information in the medical record about the occurrence; however, this will not alert the risk management system. The nurse should not document in the client's medical report that an occurrence report has been filed because this will alert all healthcare team members. The nurse should document in the client's medical report that the primary healthcare provider has been contacted because it might be useful in defending a lawsuit, but this action will not be a beneficial way to alert the risk management system.
A client on antipsychotic drug therapy develops Parkinsonism. Which drugs would be beneficial for the client? Select all that apply.
2) Benztropine 3) Amantadine 5) Diphenhydramine Rationale: Benztropine is a centrally-acting anticholinergic drug that can be used to treat symptoms of parkinsonism associated with antipsychotic drugs. Amantadine is also used to treat antipsychotic-induced parkinsonism. Diphenhydramine is another centrally-acting anticholinergic drug that can be used to treat symptoms of antipsychotic-induced parkinsonism. Levodopa and direct dopamine agonists such as bromocriptine should be avoided in antipsychotic-induced Parkinsonism because these drugs activate dopamine receptors, which might counteract the beneficial effects of antipsychotic treatment.
A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, what term does the nurse use to document this gait?
2) Shuffling Rationale: With a shuffling gait [1] [2] [3] the steps are short and dragging; this is seen with basal ganglia defects. Ataxia is a staggering gait often associated with cerebellar damage. Scissoring is associated with bilateral spastic paresis of the legs. An asymmetric gait is associated with weakness of or pain in one lower extremity.
A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred?
2) gradually Rationale: The onset of this disease is not sudden, but insidious, with a prolonged course and gradual progression. The onset is slow and gradual. The onset is not irregular; there is a gradual, regular progression of symptoms.
A nurse determines that a client exhibits the characteristic gait associated with Parkinson disease. How should the nurse describe this gait when documenting on the client's progress report?
3) Shuffling Rationale: Steps are short and dragging (shuffling); this is seen with defects of the basal ganglia. Spastic gait, short steps with dragging of foot, is associated with neurogenic causes like cerebral palsy. Steppage gait is when foot slaps down and is associated with peroneal nerve injury or paralyzed dorsiflexor muscles. Scissoring gait is associated with bilateral spastic paresis of the legs as occurs in cerebral palsy or hemiplegia.
A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients?
3) Difficulty swallowing Rationale: Difficulty swallowing (dysphagia) is a manifestation of both neurologic disorders. With Parkinson disease there is a progressive loss of spontaneity of movement, including swallowing, related to degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain. With myasthenia gravis there is a decreased number of acetylcholine (Ach) receptor sites at the neuromuscular junction, which interferes with muscle contraction, impairing muscles involved in chewing, swallowing, speaking, and breathing. A cogwheel gait is associated with Parkinson disease, not myasthenia gravis. Impaired cognition is associated with Parkinson disease, not myasthenia gravis. Nonintention tremors are associated with Parkinson disease, not myasthenia gravis. The nonintention tremors associated with Parkinson disease result from the loss of the inhibitory influence of dopamine in the basal ganglia, which interferes with the feedback circuit within the cerebral cortex.
A client is receiving an antipsychotic medication. When assessing the client for signs and symptoms of pseudoparkinsonism, the nurse will be alert for which complication?
3) Muscle tremors Rationale: Drug-induced parkinsonism presents with the classic triad of adaptations associated with Parkinson disease: rigidity, slowed movement (bradykinesia), and tremors. The anticholinergic effects of antipsychotic medication cause dry mouth, not drooling. Neither dry mouth nor drooling is related to pseudoparkinsonism. Blurred vision and photosensitivity are side effects of anticholinergic, not antipsychotic, medications.
A nurse is assessing a client with Parkinson disease. Which assessment finding indicates the presence of bradykinesia?
4) Lack of spontaneous movement. Rationale: Bradykinesia is a slowing down in the initiation and execution of movement. Tremors are more prominent at rest and are known as nonintention, not intention, tremors. Cogwheel rigidity, not flaccidity, occurs because the disorder causes sustained muscle contractions. The limbs are rigid and move with a jerky quality; the limbs are not paralyzed.
A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include?
4) Passive range-of-motion exercises at least every eight hours. Rationale: Passive range-of-motion exercises at least every eight hours maintain the range of joint movement with a minimum of energy expenditure by the client. Ambulation may fatigue the client and does not provide sufficient movement of the upper extremities. Isometric exercises do not provide the joint movement necessary to prevent contractures. Active range-of-motion exercises at least every four hours increase the client's metabolic rate and need for oxygen; the client's ability to meet increased oxygen demand is decreased in the presence of pneumonia.
A client with Parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. What is the nurse's priority intervention?
4) make arrangements immediately for further medical evaluation by the client's primary healthcare provider. Rationale: Numbness, a sensory deficit, is inconsistent with parkinsonism; further medical evaluation is necessary. Numbness, even in the absence of other problems, may be indicative of an impending brain attack (cerebrovascular accident, CVA). This symptom is not caused by parkinsonism; increasing the dosage of the anticholinergic medication will not be helpful. Stressing the importance of having the client call the primary healthcare provider as soon as possible can cause a delay in the client's receiving immediate medical attention.
A nurse administers carbidopa-levodopa to a client with Parkinson disease. Which therapeutic effect does the nurse expect the medication to produce?
4) replacement of a neurotransmitter in the brain. Rationale: Carbidopa-levodopa is used because levodopa is the precursor of dopamine. It is converted to dopamine in the brain cells, where it is stored until needed by axon terminals; it functions as a neurotransmitter. Regeneration of injured thalamic cells is not an action of this drug; neurons do not regenerate. Increase in acetylcholine production and improvement in myelination of neurons are not actions of this drug.
