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?


  1. A 12-lead electrocardiogram.
    • Rationale:
  2. If bowel sounds are hypo or hyperactive.
    • Rationale:
  3. Pupil size and pupillary response.
    • Rationale:
  4. Coagulation laboratory tests.
    • Rationale:



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.

Learning Outcomes

Test Taking Tip

Video Rationale