A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse?

Choice A reason: Feeling guilty about drinking (CAGE’s “G”) suggests awareness of problematic use, indicating psychological dependence. However, guilt is less specific than morning drinking, as it may occur in binge or social drinking without physical addiction. Morning drinking reflects physiological dependence, a stronger marker of chronic alcoholism.

Choice B reason: Needing a morning drink (CAGE’s “E” for eye-opener) indicates physical dependence, a hallmark of alcoholism. This reflects tolerance and withdrawal, where alcohol stabilizes GABA/glutamate imbalances to prevent symptoms like tremors. It’s the most specific indicator, showing the body’s reliance on alcohol, central to alcoholism’s pathophysiology.

Choice C reason: Annoyance at drinking criticism (CAGE’s “A”) suggests defensiveness, possibly indicating psychological dependence. It’s less specific than morning drinking, reflecting social dynamics rather than physical addiction. Alcoholism involves physiological changes, and morning drinking directly demonstrates the body’s need for alcohol to manage withdrawal, making this less indicative.

Choice D reason: Feeling the need to cut down (CAGE’s “C”) shows recognition of excessive drinking but is less specific than morning drinking, which signifies physical dependence from chronic alcohol-induced neurotransmitter changes. This question captures awareness but not the physiological addiction that morning drinking indicates, central to diagnosing alcoholism.

Choice A reason: Protein and albumin reflect nutritional or liver status but are unaffected by enoxaparin, a low-molecular-weight heparin inhibiting factor Xa. These do not monitor anticoagulation effects or complications like bleeding. CBC is critical, as enoxaparin increases bleeding risk, requiring platelet and hemoglobin monitoring to detect serious hematological issues.

Choice B reason: Enoxaparin, an anticoagulant, heightens bleeding risk and can cause thrombocytopenia. Monitoring CBC, especially platelets and hemoglobin, detects heparin-induced thrombocytopenia (HIT) or hemorrhage. This ensures early identification of complications, allowing timely intervention to prevent severe bleeding or thrombosis, making CBC the most critical test for safe administration.

Choice C reason: BUN and creatinine assess renal function, relevant for renally cleared drugs, but enoxaparin is primarily liver-metabolized. Renal monitoring is secondary unless severe impairment exists. CBC is more urgent, as enoxaparin’s anticoagulant effect increases bleeding risk, necessitating hematological surveillance to prevent life-threatening complications.

Choice D reason: Electrolytes like potassium or sodium are not directly affected by enoxaparin’s action on the coagulation cascade. Imbalances may occur in critical illness but are not primary concerns. CBC monitoring for bleeding or thrombocytopenia is critical, as enoxaparin’s anti-Xa activity poses hematological risks requiring immediate attention.