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A nurse is assessing a client who has had a suspected cerebrovascular accident the nurse should place the priority on which of the following findings?

A. Blood pressure
B. Pupil size and reaction to light
C. Respiratory rate
D. Grip strength

1 Answer

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Final answer:

The priority assessment for a suspected cerebrovascular accident is the respiratory rate, as it reflects the most immediate life-threatening condition and requires prompt address.

Step-by-step explanation:

When assessing a client who has had a suspected cerebrovascular accident (CVA) or stroke, a nurse should place priority on the finding that reflects the most immediate life-threatening condition. Among the options provided - blood pressure, pupil size and reaction to light, respiratory rate, and grip strength - the primary focus should be on the respiratory rate. This is because airway and breathing are critical and can be compromised following a stroke, posing a significant risk to the patient's life. An abnormal respiratory rate may indicate brain stem involvement or decreased consciousness, which requires immediate intervention.

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