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Original Question
The dient is a 76-year-old female who arrived at the emergency department (ED) via-ambulance from an assisted living facility after a fall. The client called for help using her medical alert necklace. Reports feeling dizy and lightheaded for the past two days.The dient is unable to recall the events that led up to the fall and states, ‘I do not know how long I was down. Past medical history includes chronic cbstructive pulmonary disezse (COPD), hypertension (HTN), and carotid artery stenosis.Smokes half a patk of cigarettes daily for 40 years.Attempted to quit smoking five years ago after a right carotid endarterectomy. 1620Received report from triage nurse. Client returning from computed tomography (CT) department. The client is alert and oriented times3. Unable to recall details of her fall. Heart rhythm regular. Lung sounds are diminished throughout.Placed on oxygen 1 L/minute via nasal canal.Bruising noted to left arm and small laceration on the left chin from the fall. Pain rated 3 on a scale of 0 to 10. Carotid ultrasound performed at bedside. Laboratory specimens drawn. Preparing the client for transfer to the stroke unit, calling to give report.1640Transferred dient to the floor. Situation, background, assessment, recommendation (SBAR) 1600Vital signs on arrival Temperature: 98.9\deg F(37. 1\deg C) orally Heart rate: 101 beats/minute Respirations: 22 breaths/minute Blood pressure: 156/90 mm Hg Oxygen saturation: 92% on room air1635Vital signs Temperature: 98.6\deg F (37\deg C) orally Heart rate: 98 beats/minute Respirations: 22 breaths/minute Blood pressure: 160/92 mm Hg Oxygen saturation: 93% on 1 L/minute oxygen via nasal cannula Computed tomography (CT) of brain: Negative. Carotid ultrasound: Left carotid 80% stenosis. The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.Which assessment(s) should the nurse conduct? Select all that apply.A Romberg’s testB Cranial nervesC Glasgow coma scaleD Pupil sizeE Brudzinski reflexesF Level of consciousnessG Muscle tone..
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