What is the priority nursing assessment in the first 24 hours after admission of the client with thrombotic CVA?
A. Pupil size and pupillary response
B. Cholesterol level
C. Echocardiogram
D. Bowel sounds
Correct Answer: A. Pupil size and papillary response
It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brain stem is intact. Pupil size and equality is determined by balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.
Option B: The cholesterol levels may be monitored after the client has been cleared from imminent danger. Closely assess and monitor neurological status frequently and compare with baseline. Closely assess and monitor neurological status frequently and compare with baseline.
Option C: Echocardiogram can be done once the patient has been stabilized. Assess heart rate and rhythm, and assess for murmurs. Changes in rate, especially bradycardia, can occur because of the brain damage. Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA (stroke after MI or from valve dysfunction).
Option D: Assessing the bowel sound is unnecessary for clients undergoing CVA. Assess higher functions, including speech, if the patient is alert. Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration or increased ICP.