The nurse receives report for clients on the neurology floor. Which client is important for the nurse to assess first?

Question

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New-onset agitation is a change in mental status for someone with dementia and requires assessment. It is possible for a client to develop delirium in addition to dementia. Delirium is a sign of a different issue, such as worsening infection/condition, fluid and electrolyte imbalance, or drug-drug interaction. (Option A) Bowel and/or bladder incontinence or retention is an expected sign/symptom in clients with multiple sclerosis. (Option B) Guillain-Barré syndrome is ascending bilateral paralysis from segmental demyelination (remyelination eventually occurs). Normal deep tendon reflexes are 2+. Hypotonia (muscle weakness) and areflexia (loss of reflexes) are common manifestations. The current level of paralysis is at the knees and is therefore not the priority as it has not yet reached the diaphragm. (Option C) Drooling, lack of blinking, mask-like facial expressions, and lack of swinging arms with walking are expected findings of Parkinson disease. This loss of autonomic movements results from alterations of the basal ganglia and extrapyramidal portion of the central nervous system. Educational objective: A change in level of consciousness from baseline is concerning even when the client has dementia.

The Nurse Receives Report for Clients on the Neurology Floor