Case Study: Neurological Assessment (2023/2024) 100% Pass

Case Study: Neurological Assessment (2023/2024) 100% Pass Communication and Documentation: The nurse begins the admission assessment with the collection of assessment data that is immediately entered into the electronic health record (EHR). When eliciting data about possible neurological problems, what information should the nurse obtain from the client? (Select all that apply. One, some, or all options may be correct.) A. Any difficulty speaking or swallowing. B. Ever hear voices that no one else hears. C. Headache frequency and location. D. Any numbness, tingling, or weakness of extremities. E. Did the head hit the floor with syncopal episode. A. Any difficulty speaking or swallowing. C. Headache frequency and location. D. Any numbness, tingling, or weakness of extremities. E. Did the head hit the floor with syncopal episode. Based on the client's recent history of loss of consciousness and falling, what additional assessment takes priority? A. Pedal pulse volume. B. Deep tendon reflexes. C. Two-point discrimination. D. Blood pressure and heart rate and rhythm. D. Blood pressure and heart rate and rhythm. Rationale: Hypotension and bradycardia can cause a loss of consciousness. Bradycardia may also be a sign of increased intracranial pressure.If the client has hypertension, it places the client at increased risk for a hemorrhagic stroke. If the client has cardiac irregularity, such as atrial fibrillation, the client should be evaluated and treated to prevent an embolic stroke. The nurse assesses the client's vital signs and level of consciousness and then proceeds to interview the client. To determine what happened to the client prior to the loss of consciousness, the nurse should obtain what information from the client? (Select all that apply. One, some, or all options may be correct.) A. Ask the client to stick out their tongue. B. Ask the client if they ever feel lightheaded or dizzy. C. Ask the client if they have any problems with smell. D. Ask the client if the dizziness occurs when they change positions. E. Ask the client if they felt like the room was suddenly spinning before they fell. B. Ask the client if they ever feel lightheaded or dizzy. D. Ask the client if the dizziness occurs when they change positions. E. Ask the client if they felt like the room was suddenly spinning before they fell. During the interview, the nurse observes the client's speech patterns. The client seems to have difficulty choosing and forming some words. What action should the nurse take? A. Affirm the client's difficulty and ask about when this first started. B. Fill in the conversation with the words the client is attempting to say. C. Offer to complete the interview at a later time after the client has rested. D. Allow the client to respond and ignore any difficulty to avoid embarrassment. A. Affirm the client's difficulty and ask about when this first started. Rationale: This action demonstrates caring and also enables the nurse to obtain a more complete history related to the onset of the client's symptoms. Physiologic Adaptation: Before continuing the interview and assessment, the nurse enters the following initial data collected into a tablet: The client demonstrates difficulty speaking and previously reported feeling weak, passing out, and falling at home. Vital signs are currently T 97° F (36o C), Blood Pressure 140/88 mmHg, heart rate 92beats