A nurse is caring for a client who is newly diagnosed with Parkinson's disease. The client states, "I have no idea why I got this." Which of the following is the most important question the nurse should ask this client while performing the assessment?

Choice A Reason:

Muscle strength is correct. Assessing muscle strength is essential to determine if there are any neurological deficits or weakness that could indicate a neurological condition or injury. Sudden falls can be indicative of various neurological issues, such as stroke or transient ischemic attack (TIA). Assessing muscle strength helps identify any motor impairments or weakness that could contribute to the fall.

Choice B Reason:

Facial symmetry is correct. Assessing facial symmetry is crucial to identify any signs of facial droop, which could indicate a neurological deficit such as a stroke or Bell's palsy. Facial asymmetry may suggest damage to the facial nerve or other neurological issues.

Choice C Reason:

Peripheral pulses is incorrect. While assessing peripheral pulses is important for evaluating circulation, it may not be the priority assessment in this scenario where the client has suddenly fallen and may be experiencing neurological symptoms. Neurological deficits, such as weakness or changes in facial symmetry, vision, or speech, are more indicative of acute neurological issues like stroke or transient ischemic attack (TIA), which require immediate attention and intervention. In emergency situations, prioritizing assessments related to potential life-threatening conditions such as neurological deficits takes precedence over assessing peripheral pulses.

Choice D Reason:

Vision changes is correct. Assessing for vision changes is important to identify any visual disturbances or deficits that could contribute to falls or indicate underlying neurological issues such as a stroke or transient ischemic attack (TIA). Visual disturbances may include blurriness, double vision, or loss of vision in one or both eyes.

Choice E Reason:

Aphasia is incorrect. Assessing for aphasia, which is the inability to understand or express speech, is essential to identify any language deficits that could indicate a neurological condition such as a stroke. Aphasia may present as difficulty speaking, understanding language, or both.

Choice A Reason:

"Do panting breaths several times a day." This statement is inappropriate. Panting breaths involve rapid, shallow breathing similar to what a dog does when it's hot. This technique may not be as effective in clearing mucus or promoting lung expansion compared to deep coughing. While panting breaths may have some benefits in promoting ventilation and increasing lung volume, they may not be as targeted or efficient in preventing atelectasis as other techniques such as deep coughing

Choice B Reason:

"Perform deep coughing twice a day." This statement is correct. Deep coughing helps clear mucus and secretions from the airways, reducing the risk of blockages that can lead to atelectasis. It promotes airway clearance and lung expansion, maintaining respiratory function. Regular deep coughing is particularly important for individuals with spinal cord injuries, as they may have impaired cough reflexes or weakened respiratory muscles, increasing their vulnerability to atelectasis.

Choice C Reason:

"Strengthen your chest muscles by performing therapy exercises." This statement is incorrect. While strengthening chest muscles through therapy exercises can be beneficial for overall respiratory health, it may not directly target the prevention of atelectasis. Atelectasis is primarily caused by the collapse of lung tissue due to mucus buildup or reduced lung expansion, rather than weakness of chest muscles. While therapy exercises may have other benefits such as improving respiratory function and endurance, they may not be the most effective strategy for preventing atelectasis in individuals with spinal cord injuries.

Choice D Reason:

"Get plenty of rest throughout the day." This statement is incorrect. Rest is important for overall health and well-being, but it may not directly contribute to the prevention of atelectasis. Inactivity and prolonged bed rest can actually increase the risk of atelectasis by reducing lung expansion and promoting mucus accumulation in the airways. While adequate rest is necessary for recovery and energy conservation, it should be balanced with activities that promote lung expansion and airway clearance, such as deep breathing exercises and mobility.