Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?

A. Remove clothing: While removing clothing may be necessary for a thorough assessment and treatment, maintaining cervical spine precaution takes precedence to prevent potential spinal cord injury in clients with a history of trauma, such as a fall from a significant height.

B. Maintain cervical spine precaution: Maintaining cervical spine precaution by stabilizing the cervical spine and immobilizing the neck is crucial to prevent further injury to the spinal cord in clients with a history of trauma until spinal injury is ruled out or managed.

C. Perform a mental status exam: While assessing the client's mental status is important for evaluating neurological function, it is not the first priority in a client with potential spinal cord injury following a fall.

D. Assess for facial lacerations: Assessing for facial lacerations is important for identifying and managing potential facial injuries, but it is not the first priority in the primary assessment of a client with a history of trauma and potential spinal cord injury.

A. Administer an oral analgesic: Administering analgesics may provide relief from pain, but it does not address the underlying cause of the headache and stiff neck. Assessing the client's neurological status is the priority to determine the severity and potential cause of the symptoms.

B. Perform a complete blood count: While laboratory tests may be necessary to further evaluate the client, they are not the first action to take when the client presents with symptoms suggestive of a neurological emergency such as meningitis. Assessing the client's neurological status and ruling out serious conditions take precedence.

C. Evaluate the client's neurological status: Assessing the client's neurological status, including level of consciousness, motor and sensory function, and signs of meningeal irritation (such as neck stiffness), is crucial for identifying potential neurological emergencies such as meningitis and guiding further management.

D. Check the client's temperature: While obtaining vital signs, including temperature, is important in the assessment of a client with suspected meningitis, it is not the first action to take. Assessing the client's neurological status and initiating appropriate interventions based on the findings are the priority.