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A client is admitted to the hospital with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment requires Immediate Intervention by the nurse?

a. Orientation to person and place only.
b. Unequal bilateral hand grip strengths
c. Pupillary changes to ipsilateral dilation.
d. Left-sided facial drooping and dysphagia.

User Wax
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Final answer:

The immediate intervention required is addressing pupillary changes to ipsilateral dilation which may indicate increased intracranial pressure in a patient with a suspected right hemisphere stroke.

Step-by-step explanation:

The neurovascular assessment that requires immediate intervention by the nurse for a client admitted to the hospital with symptoms consistent with a right hemisphere stroke is c. Pupillary changes to ipsilateral dilation.

Pupillary changes such as ipsilateral dilation may indicate increased intracranial pressure and are a significant finding requiring urgent intervention. In contrast, orientation issues, unequal bilateral hand grip strengths, and left-sided drooping and dysphagia, while also important, do not typically signify an emergent condition like herniation, which could be the case with pupillary changes.

It is crucial for care providers to conduct a rapid assessment of neurological function to identify the loss of abilities and determine the location of the CNS injury. Timely diagnosis and treatment are essential in effectively managing a stroke and minimizing its long-term impacts, such as disability. Interventions can include administering medications like aspirin to prevent further clotting if the cause is an embolus, and conducting a CT scan to assess the extent of the stroke.

User Mandeep Pasbola
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