A nurse is caring for a client who reports continuing problems related to migraines. The nurse is assessing the psychosocial impact of migraines on the client. Which of the following questions should the nurse include in the assessment?
(Select All that Apply.)

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:

"Antibiotics are seldom prescribed," is not an appropriate response as it does not address the client's concern about the cost of medication and may also be inaccurate depending on the specific diagnosis and treatment plan.

Choice B Reason:

"Maybe you can borrow some money to get the medicine," may not be feasible for the client and can also be perceived as insensitive or dismissive of their financial situation.

Choice C Reason:

"Your health care provider may be able to give you free samples. “offers a compassionate and practical solution to the client's concern about the cost of medication. Many healthcare providers have access to free medication samples provided by pharmaceutical companies, which they can offer to patients who have financial difficulties.

Choice D Reason:

"Where did your money go this month?" is judgmental and inappropriate. It may make the client feel ashamed or defensive about their financial situation, which is not conducive to a therapeutic nurse-client relationship. Additionally, the client's financial decisions are not relevant to their need for medical treatment.