A client is brought to the emergency department (ED) by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client
Which finding would indicate the need for a more detailed neurological assessment of this client?
1. Asymmetry of the client's smile.
2. Grimacing with movement.
3. Talking in a loud voice.
4. Inability to follow directions.
Correct Answer: 1
Asymmetry of facial expressions is a cue that the client may be experiencing a neurological problem and the nurse should perform an assessment of the cranial nerves. Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem. Talking in a loud voice may cue the nurse that the client has hearing loss. The client's inability to follow directions may also be the result of a hearing loss.
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