NORCET 9 Prelims-2025: What is the priority nursing assessment in the first 24 hours after admission of a client with a thrombotic C…

NORCET 9 Prelims-2025

Medical & Surgical Nursing

Medium

Appeared in: NORCET 9 Prelims-2025

Explanation

The highest priority in the first 24 hours after a thrombotic CVA is monitoring for changes in neurological status to detect complications like increased intracranial pressure (ICP).
Assessing pupil size and pupillary response is a rapid, non-invasive, and reliable method to evaluate brainstem function and identify neurological deterioration.
Changes such as pupil dilation, inequality (anisocoria), or a sluggish reaction to light can be early signs of rising ICP or brainstem compression, requiring immediate medical intervention to prevent irreversible brain damage.

Option B: Assessing cholesterol level is not an immediate priority. It is a diagnostic measure related to long-term risk factor management.
Option C: An echocardiogram is a diagnostic procedure to determine the cause of the stroke (e.g., a cardioembolic source), not a priority nursing assessment for monitoring the patient's immediate condition.
Option D: While assessing bowel sounds is part of a comprehensive nursing assessment, it is not a priority in the acute phase of a stroke. It does not reflect the immediate life-threatening neurological risks.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Priority nursing assessment in the acute phase of a thrombotic CVA in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Nurses on a stroke unit perform frequent neurological checks, often every 15-60 minutes in the acute phase, which always includes assessing pupils, level of consciousness, and motor strength.
A sudden change in pupil response is a neurological emergency. The nurse must immediately notify the physician or the rapid response team, as this may signal impending brain herniation.
What if? If the patient's Glasgow Coma Scale (GCS) score suddenly dropped by 2 points, the priority would be to first ensure a patent airway (ABCs), and then immediately report the change in GCS and pupillary findings to the provider, as this indicates significant neurological decline.

How to Approach the Question

First, identify the keywords in the question: 'priority', 'first 24 hours', and 'thrombotic CVA'. This combination directs you to focus on immediate, life-threatening complications of an acute ischemic stroke.
Second, consider the pathophysiology. A CVA is a brain injury. Therefore, the primary organ at risk is the brain, and assessments related to its function are paramount.
Third, evaluate the options based on urgency. Ask yourself, 'Which assessment will give me the most critical information about the patient's immediate survival and neurological stability?'
Fourth, compare the assessments. Pupil checks directly monitor for brainstem compression and increased ICP. The other options relate to finding the cause (echocardiogram), long-term risk (cholesterol), or secondary complications of immobility (bowel sounds).
Finally, select the option that addresses the most immediate life-threat, which is the neurological assessment of pupil size and response.

Concept Tested & Keywords

Concept Tested: Priority nursing assessment in the acute phase of a thrombotic CVA.
Stem keywords: priority nursing assessment, first 24 hours, thrombotic CVA
Lead-in keywords: priority
Clinical cues: Timeframe: first 24 hours - indicates acute phase care
Clinical cues: Diagnosis: thrombotic CVA - highlights risk of neurological deterioration and increased intracranial pressure.

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