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: Instruct the client to wear a hospital gown every day, even when out of bed

This intervention does not directly address the prevention of complications related to immobility. Wearing a hospital gown may be necessary for medical reasons, but it does not promote mobility or prevent complications such as pressure ulcers, muscle atrophy, or deep vein thrombosis (DVT). Encouraging the client to wear regular clothes when out of bed might actually promote a sense of normalcy and encourage more movement.

Choice B Reason: Have the client remain in bed for self-care activities

Keeping the client in bed for self-care activities is counterproductive in preventing complications of immobility. Prolonged bed rest can lead to muscle atrophy, decreased joint mobility, and increased risk of pressure ulcers and DVT. Encouraging the client to get out of bed and perform self-care activities while standing or sitting can help maintain muscle strength and joint flexibility.

Choice C Reason: Encourage the client to sit in the chair for all meals

Encouraging the client to sit in a chair for meals is an effective intervention to prevent complications of immobility. Sitting up helps improve digestion and respiratory function and reduces the risk of pressure ulcers by changing the pressure points on the body. It also promotes muscle activity and circulation, which are crucial in preventing DVT and maintaining overall physical health.

Choice D Reason: Elevate the head of the bed to 30° to 45° for medication administration

While elevating the head of the bed can be beneficial for certain medical conditions and for medication administration, it does not significantly contribute to preventing complications of immobility. This position can help with respiratory function and prevent aspiration during medication administration, but it does not promote overall mobility or prevent muscle atrophy and pressure ulcers.

Choice A Reason: Alternate the use of ice and heat

Alternating the use of ice and heat is not typically recommended for the initial treatment of a soft-tissue injury. Ice is generally used during the first 24-48 hours to reduce swelling and inflammation. Heat can be applied later to help relax muscles and improve blood flow, but it should not be used immediately after an injury as it can increase swelling.

Choice B Reason: Apply ice pack intermittently

Applying the ice pack intermittently is important to prevent skin damage and frostbite. It is generally recommended to apply ice for 15-20 minutes at a time, followed by a break of at least 20 minutes before reapplying. This helps to reduce swelling and pain without causing harm to the skin and underlying tissues.

Choice C Reason: Do not place ice pack directly on the skin

Placing an ice pack directly on the skin can cause frostbite and damage to the skin and tissues. It is important to wrap the ice pack in a thin cloth or towel before applying it to the injured area. This provides a barrier that protects the skin while still allowing the cold to penetrate and reduce swelling.

Choice D Reason: Leave ice pack on for no more than 20 minutes at a time

Leaving the ice pack on for no more than 20 minutes at a time is crucial to prevent frostbite and skin damage. Prolonged exposure to cold can cause harm, so it is important to limit the duration of each application and take breaks in between.