The nurse reports that a client is at risk for a stroke based on which assessment finding?

Choice A reason: Palpable cervical lymph nodes suggest infection or malignancy, not stroke risk. Stroke is linked to vascular issues like carotid stenosis, detected by bruit. Lymph nodes are unrelated to cerebrovascular pathology, making this finding irrelevant for identifying stroke risk in the client.

Choice B reason: Carotid bruit indicates turbulent flow from stenosis, a major stroke risk due to potential embolism or reduced cerebral perfusion. This vascular finding directly correlates with ischemic stroke, making it the most critical assessment to report for stroke prevention and evaluation.

Choice C reason: Nuchal rigidity suggests meningitis or subarachnoid hemorrhage, not ischemic stroke risk. Carotid bruit is a specific precursor to embolic stroke, and nuchal rigidity addresses different neurological conditions, making this finding less relevant for stroke risk assessment.

Choice D reason: Jugular vein distention indicates heart failure or venous pressure, not arterial stroke risk. Carotid bruit directly relates to cerebrovascular disease, a stroke precursor, making jugular distention irrelevant, as it reflects cardiovascular, not cerebrovascular, pathology in stroke risk evaluation.

Choice A reason: Assessing peripheral pulses is critical first, as foot pain in an external fixation device may indicate vascular compromise, like arterial occlusion or compartment syndrome. Absent pulses signal ischemia, requiring urgent intervention to prevent tissue loss, making this the priority to ensure limb perfusion.

Choice B reason: Administering PRN pain medication relieves discomfort but does not address potential vascular or compartment issues causing foot pain. Pulse assessment identifies life-threatening ischemia, and pain relief is secondary, as untreated vascular compromise risks permanent damage, making this action less urgent.

Choice C reason: Observing for swelling evaluates edema but is less specific than pulse assessment. Foot pain may stem from ischemia, and absent pulses indicate urgent vascular issues. Swelling is a secondary sign, making pulse checks the priority to diagnose critical causes of pain.

Choice D reason: Auscultating blood pressure is unrelated to foot pain in a fixation device. Pain may indicate vascular or neurological compromise, and pulse assessment directly evaluates perfusion, critical for preventing ischemia, making blood pressure irrelevant to the immediate issue of localized pain.