The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse? Select all that apply.

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The nurse performs a neurological assessment to evaluate for changes in motor and sensory functions by assessing pupils, cranial nerves, and neuromuscular functioning. The neck should be supple and able to be flexed toward the chest. Nuchal rigidity requires follow-up due to possible meningeal irritation related to infection (eg, meningitis) (Option A). A new-onset unilateral drift of a limb could indicate a stroke. The nurse assesses for other strokelike symptoms (eg, changing level of consciousness, asymmetrical smile, garbled speech), activates the facility stroke protocol, and notifies the health care provider accordingly (Option C). Normal pupils are 3-5 mm in diameter. Pupil dilation can be the result of medication use or neurological causes (eg, increased intracranial pressure, brain herniation) (Option D). (Option B) Oculocephalic reflex (doll's eyes) is an expected finding indicating an intact brainstem. It is tested by rotating the head and watching for the eyes to move simultaneously in the opposite direction. The test is not performed if spinal trauma is suspected. (Option E) The normal finding in adults is an absent Babinski reflex (ie, toes point downward with stimulus to the sole). The presence of Babinski reflex (ie, toes fan outward and upward with stimuli) is expected in infants up to age 1, but in an adult may indicate a brain or spinal cord lesion. Educational objective: Abnormal neurological assessments include nuchal rigidity; new-onset unilateral drift of a limb; pupils <3 mm or >5 mm in diameter; absent oculocephalic reflex; and presence of Babinski reflex in an adult client.

The Nurse Assesses a Newly Admitted Adult Client on a Neurological