Exhibits Which assessment(s) should the nurse conduct? Select all that apply.

A. Muscle tone: Assessing muscle tone is important to evaluate for motor deficits or neurological impairments that may have contributed to the fall or been caused by a cerebrovascular event. B. Level of consciousness: The client’s inability to recall the events leading to the fall requires an assessment of mental status and level of consciousness to identify potential cognitive or neurological issues. C. Cranial nerves: A cranial nerve assessment can detect focal neurological deficits indicative of stroke or other neurological conditions. D. Brudzinski reflexes: This reflex is assessed for meningitis and would not be relevant in this scenario as the client does not exhibit symptoms such as fever, nuchal rigidity, or photophobia. E. Pupil size: Changes in pupil size and reactivity may indicate increased intracranial pressure or other neurological changes. F. Glasgow Coma Scale (GCS): This scale is crucial for assessing the client’s neurological status and level of consciousness, especially given the fall and dizziness. G. Romberg's test: This test evaluates balance and proprioception, but it is less appropriate in the acute setting when the priority is to assess for neurological deficits related to the fall or potential cerebrovascular event.