A student nurse is caring for a client with acute hemorrhagic stroke who was admitted 1 day ago. Which is the priority assessment finding for the student to report to the primary nurse?
The client's refusal to take the prescribed antiplatelet
Blood pressure 174/84
difficulty speaking
Blood glucose of 120
The Correct Answer is C
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A GCS score of 3 for eye opening indicates that the client opens their eyes in response to speech. This accurately reflects the client's level of responsiveness.
B. A GCS score of 5 for motor response indicates that the client localizes pain or can follow simple motor commands. However, this does not fully encapsulate the most appropriate conclusion, given the specific GCS score for eye opening.
C. A total GCS score of 13 (3 for eye opening, 5 for verbal response, and 5 for motor response) suggests mild impairment, not unconsciousness. Unconsciousness is typically indicated by a GCS score of 8 or below.
D. A GCS score of 5 for verbal response indicates the client is oriented and can respond verbally, so they are capable of making vocal sounds.
Correct Answer is B
No explanation
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