Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

Rationale: A. Romberg’s test: This test assesses balance and coordination by asking the client to stand with eyes closed. It requires the client to be ambulatory and stable, which is unsafe during an acute stroke evaluation or immediately after a fall, making it inappropriate at this stage. B. Pupil size: Assessing pupil size and reactivity helps identify changes in intracranial pressure or cranial nerve III involvement. Unequal or sluggish pupils may indicate evolving neurological compromise, making this a critical part of the focused neurological assessment. C. Glasgow coma scale: The Glasgow Coma Scale (GCS) objectively evaluates eye, verbal, and motor responses to assess consciousness. Monitoring the GCS provides a baseline and helps detect subtle neurological deterioration, especially in stroke-prone clients. D. Muscle tone: Evaluating muscle tone determines the presence of spasticity, rigidity, or flaccidity, which may suggest stroke-related motor deficits or evolving neurological injury. This helps in identifying affected areas of the brain and guiding rehabilitation needs. E. Level of consciousness: Assessing level of consciousness (LOC) is essential in detecting early neurological changes and potential progression toward decreased responsiveness. LOC fluctuations often precede other signs of cerebral dysfunction. F. Brudzinski reflexes: Brudzinski’s sign is used to assess meningeal irritation seen in meningitis, not cerebrovascular events. Performing this reflex test is unnecessary and unrelated to a stroke or carotid stenosis assessment. G. Cranial nerves: Cranial nerve assessment identifies deficits such as facial droop, dysphagia, or vision changes associated with stroke. Evaluating these nerves helps localize the lesion and determine the extent of neurological impairment.