What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
A. Cholesterol level
B. Pupil size and pupillary response
C. Bowel sounds
D. Echocardiogram
Correct Answer: B. Pupil size and pupillary 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 a balance between parasympathetic and sympathetic innervation. Response to light reflects the combined function of the optic (II) and oculomotor (III) cranial nerves.
Option A: Cholesterol level is an assessment to be addressed for long-term healthy lifestyle rehabilitation. Secure referral to physical therapy and occupational therapy if needed. Reinforce special mobilization techniques such as proprioceptive neuromuscular rehabilitation, neurodevelopmental treatment, motor relearning program, and constraint-induced movement therapy per the client’s individualized rehabilitation program.
Option C: Bowel sounds need to be assessed because an ileus or constipation can develop, but is not a priority in the first 24 hours. Identify previous bowel habits and reestablish a normal regimen. Increase bulk in diet, encourage fluid intake, increased activity. Assists in the development of retraining programs (independence) and aids in preventing constipation and impaction (long-term effects).
Option D: An echocardiogram is not needed for the client with a thrombotic stroke. Closely assess and monitor neurological status frequently and compare with baseline. Assesses trends in the level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression of damage. May also reveal the presence of TIA, which may warn of impending thrombotic CVA.
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