A client is brought to the emergency department by ambulance after being found on the floor by a family member. The nurse begins the assessment of the client
Which of the following findings would indicate, to the nurse, 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
1
Rationale 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.
Rationale 2: Grimacing with movement provides a cue that the client may be experiencing a musculoskeletal problem.
Rationale 3: Talking in a loud voice may cue the nurse that the client has hearing loss.
Rationale 4: The client's inability to follow directions may also be the result of a hearing loss.
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