Neurological Question #28
A client is admitted following a thrombotic stroke. What priority assessment is most important for the nurse to perform in the first 24 hours?
- A 12-lead electrocardiogram.
- If bowel sounds are hypo or hyperactive.
- Pupil size and pupillary response.
- Coagulation laboratory tests.
The nurse should assess pupil size and pupillary response, which may indicate changes associated with complications of the stroke. While assessing for risk of ileus is important, it is not a priority during the first hours to 24 hours of onset. Laboratory values and ECG are important; however, they will become part of routine studies and are not critical in the first 24 hours.
Test Taking Tip