Question

The nurse admits a client diagnosed with a cerebrovascular accident (CVA). Which actions are taken by the nurse to assess the client 's neurological status?

1. Obtain pulses in all four extremities.
2. Ask the client to grasp and squeeze two fingers.
3. Determine client 's orientation to person, place, and time.
4. Determine if the client has pain when walking.
5. Observe presence of the Chadwick sign.
6. Assess the client 's pupillary response.

Answer 1

To assess the client's neurological status, the nurse can obtain pulses in all four extremities, ask the client to grasp and squeeze two fingers, determine the client's orientation, and assess the pupillary response.

Step-by-step explanation:

The nurse can take the following actions to assess the client's neurological status:

1. Obtain pulses in all four extremities.
2. Ask the client to grasp and squeeze two fingers.
3. Determine the client's orientation to person, place, and time.
4. Assess the client's pupillary response.

These actions help evaluate different aspects of the client's neurological function, such as blood circulation, motor strength, cognitive orientation, and pupillary response, which can provide valuable information about the client's neurological condition.