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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.

Glasgow coma scale

Pupil size

Brudzinski reflexes

Romberg's test

Muscle tone

Level of consciousness

Cranial nerves

Answer and Explanation

Correct Answer : A,B,E,F,G

Rationale:
A. Glasgow coma scale: The Glasgow Coma Scale (GCS) assesses eye-opening, verbal response, and motor response. This is essential in a client admitted to a stroke unit to monitor changes in neurological function and detect early signs of deterioration.

B. Pupil size: Assessing pupil size and reactivity is critical because changes can indicate increased intracranial pressure or focal neurological damage. In a post-fall, stroke-risk client, monitoring pupils helps detect worsening brain injury.

C. Brudzinski reflexes: Brudzinski's sign is used to assess meningeal irritation, commonly seen in meningitis, not stroke. There is no indication of meningeal infection in this client’s presentation, so this reflex is not relevant here.

D. Romberg's test: Romberg's test evaluates balance and proprioception, typically used for clients with suspected vestibular or sensory ataxia. Given the client's acute condition and history of carotid disease, balance testing could be unsafe immediately after a fall.

E. Muscle tone: Assessment of muscle tone is important because stroke and carotid artery disease can lead to changes such as spasticity or flaccidity. Early detection of abnormal muscle tone supports quick rehabilitation planning and fall prevention strategies.

F. Level of consciousness: Monitoring level of consciousness (LOC) is crucial in stroke clients. Changes in LOC can be early indicators of worsening cerebral perfusion, hemorrhage, or new ischemic events, all of which require immediate intervention.

G. Cranial nerves: Cranial nerve assessment is essential in stroke evaluation because deficits can reveal specific areas of brain involvement. Testing functions like facial movement, swallowing, and visual fields helps complete a thorough neurological picture.

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Correct Answer is D

Explanation

Rationale:
A. "Can you recall the date the Twin Towers in New York were destroyed?": This question assesses memory, specifically long-term memory, rather than judgment. Remembering historical events evaluates cognitive recall ability but does not explore the client’s decision-making process.

B. "What is the difference between a hamster and a rabbit as a pet?": This question primarily assesses abstract thinking and categorization rather than judgment. It helps evaluate how the client organizes concepts but does not directly provide insight into practical decision-making or problem-solving skills.

C. "Should someone who lives in a glass house throw stones?": This proverb assesses abstract thinking and the ability to interpret symbolic meanings, rather than directly evaluating judgment. Interpretation of proverbs reflects cognitive function but not necessarily real-life decision-making capacity.

D. "Do you write checks if you know the bank account is overdrawn?": This question assesses practical judgment by exploring the client's ability to make appropriate decisions regarding real-world financial behavior. It directly addresses reasoning, consequences of actions, and impulse control, which are key elements of judgment evaluation.

A. Document thickened toe nails. B. Palpate and document quality of distal pulses. C. Measure ankle-brachial index (ABI). D. Measure and record dependent ankle edema.

Correct Answer is B

Explanation

Rationale:
A. Document thickened toe nails: Thickened toenails can be a sign of poor circulation associated with PVD, but documenting this alone does not provide critical information about current perfusion status. While important, it is less urgent compared to assessing the functionality of blood flow through distal pulses.

B. Palpate and document quality of distal pulses: Palpating distal pulses, such as dorsalis pedis and posterior tibial, is crucial to assess arterial blood flow to the extremities. In clients with PVD, weak or absent pulses can indicate worsening ischemia, making this assessment vital for early intervention and monitoring disease progression.

C. Measure ankle-brachial index (ABI): ABI is a non-invasive diagnostic test that measures the ratio of ankle to arm blood pressure to confirm PVD severity. It is a key diagnostic tool for PVD and provides objective data on the severity of arterial disease. However, in the context of a routine health assessment, palpating distal pulses offers immediate, albeit subjective, information about perfusion. While ABI is important, pulse assessment is often the initial and most readily available technique during a physical exam.

D. Measure and record dependent ankle edema: Dependent edema is more indicative of venous insufficiency rather than arterial PVD. Although documenting edema can assist in the overall vascular assessment, it does not directly evaluate arterial perfusion, which is the primary concern in PVD clients.

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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

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

Correct Answer is D

Explanation

While completing a health assessment for a client with peripheral vascular disease (PVD), which assessment technique is most important for the nurse to implement?

Correct Answer is B

Explanation

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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.