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Patient Data

Exhibits

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.

Brudzinski reflexes

Muscle tone

Romberg's test

Level of consciousness

Pupil size

Cranial nerves

Glasgow coma scale

Answer and Explanation

Correct Answer : B,C,D,E,F,G

A.   Brudzinski reflexes test is primarily used to assess for meningeal irritation, which is not directly related to stroke.
B.   Muscle tone assessments help to identify abnormalities in motor function, which could indicate neurological damage. Given the patient’s history and the recent fall, muscle tone should be checked for any signs of weakness or spasticity.
C.   This test evaluates the client’s balance and proprioception. It is a quick way to check for potential issues with the nervous system, such as ataxia or other motor impairments, which could be present in a client with a stroke.
D.   Assessing the level of consciousness is critical in a neurological assessment to ensure that the client is oriented and alert, which is especially important after a fall or stroke-like symptoms.
E.   Pupillary response is an essential part of a neurological exam. Checking the size and reactivity of the pupils helps to assess brainstem function and overall neurological health.
F.   Cranial nerve function should be assessed to evaluate for signs of neurological deficits. In stroke patients, cranial nerve impairments can provide important diagnostic information.
G.   The Glasgow Coma Scale (GCS) is a standard tool for assessing the level of consciousness and neurological status. It can provide valuable insights into the severity of a neurological condition, especially in post-fall or post-stroke patients.

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Correct Answer is A

Explanation

A. Icterus, or yellowing of the sclera, is a key sign of jaundice, which occurs when there is an excess of bilirubin in the blood.
B. Serum bilirubin levels are important for diagnosis but are not an immediate physical assessment.
C. Dark urine can suggest liver or bile duct issues but is not definitive for jaundice.
D. Pallor of the conjunctiva indicates anemia, not jaundice.

A. "What were you doing when you first noticed the problem?" B. "Have you taken any medications to relieve the pain?" C. "Does changing your position make the pain worse?" D. "Do you remember ever having this type of pain in the past?"

Correct Answer is A

Explanation

A. Understanding the onset and activities related to the back pain can help the nurse determine if it is musculoskeletal, posture-related, or indicative of a more serious underlying issue.
B. Asking about medication is secondary until more information is gathered about the pain's onset and nature.
C. Changing positions may be relevant later, but initially, it is important to identify any possible triggers for the pain.
D. Asking about previous pain episodes may be helpful, but understanding the current episode’s cause is more pressing.

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Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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Patient Data

Exhibits

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.