Certified Medical-Surgical Registered Nurse Practice Exam

Which factor is a priority assessment for a patient with a suspected stroke?

1. Bilateral pupil reaction

2. Respiratory rate

3. Level of consciousness

4. Skin temperature

The correct answer is: Level of consciousness

The priority assessment for a patient with a suspected stroke is the level of consciousness. This is crucial because a change in consciousness can indicate how the stroke is affecting the brain and help gauge the severity of the condition. A decreased level of consciousness could signify increased intracranial pressure or a more extensive area of brain affected by ischemia or hemorrhage. This assessment is essential for determining immediate interventions and the potential need for advanced imaging and treatment. While assessing bilateral pupil reaction, respiratory rate, and skin temperature are important in their own right, they do not provide as direct insight into the patient's neurological status or the urgency of the situation related to a suspected stroke. Changes in pupil reaction can clue in on brain function, and abnormalities in respiratory rates and skin temperature can be indicators of critical conditions, but the level of consciousness serves as a more immediate guide to the patient's neurological stability and the severity of the stroke. Therefore, focusing on the level of consciousness allows healthcare providers to triage effectively and make prompt decisions regarding intervention and care.