Medical Surgical Stroke #2

Question

A client is admitted following a thrombotic stroke. What priority assessment is most important for the nurse to perform in the first 24 hours?

Answers

  1. A 12-lead electrocardiogram.
    • Rationale:

      This answer is not correct because an ECG is not the priority assessment during the first 24 hours of a stroke. ECG will most likely be performed as part of an admission and the client may be placed on telemetry monitoring, but the priority assessment for a client with a stroke is a neurological assessment, which includes assessment of pupillary size and response.

  2. If bowel sounds are hypo or hyperactive.
    • Rationale:

      This answer is not correct because while assessing risk of ileus is important, it is not a priority during the first hours to 24 hours of onset of a stroke. Bowel obstruction is sometimes a complication of stroke but is not priority over stroke neurological assessment.

  3. Pupil size and pupillary response.
    • Rationale:

      This answer is correct because the nurse should assess pupil size and pupillary response, which may indicate changes associated with complications of the stroke. Neurological assessment is first priority with a stroke victim. Neurological assessment provides quick identification on whether a client requires immediate intervention.

  4. Coagulation laboratory tests.
    • Rationale:

      This answer is not correct because coagulation laboratories are not priority assessment. These coagulation studies will be obtained and monitored within the first 24 to 48 hours.

Overview

A thrombotic stroke is caused by a blood clot that blocks an artery. Neurological assessments, including pupil size and response, are imperative within the first 24 hours of a stroke to assess nerves involved.

Explanation

Learning Outcomes

When a blood clot blocks an artery, such as in a thrombotic stroke, it blocks flow to the brain. Priority assessment is to check for neurological deficits. Neurological assessment provides quick identification on whether a client requires immediate intervention. Pupil size and response is part of neurological assessment. It is important to check neurological status in the first 24 hours after a stroke to determine differential diagnoses, so that appropriate studies and treatment can be implemented. Although bowel sounds are important to assess, it is but not more important than neurological assessment. Coagulation laboratory tests will be indicated, but not before neurological assessments.

Test Taking Tip

Remember to consider a focused assessment when a client has an emergent condition.

Video Rationale