Physiological Adaptation Q 37

---

The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention?

  

     A. Decrease in the level of consciousness

     B. Loss of bladder control

     C. Altered sensation to stimuli

     D. Emotional lability

    

    

Correct Answer: A. Decrease in the level of consciousness

---

A further decrease in the level of consciousness may indicate an increase in intracranial pressure leading to inadequate oxygenation of the brain. A decrease in LOC may also reveal the presence of a transient ischemic attack which may warn of impending thrombotic CVA.

---

Option B: The patient post-stroke may have transient urinary incontinence due to inability to communicate needs, or impaired motor and postural control. Control of the urinary sphincter may also be lost or diminished.

Option C: Altered sensation to stimuli is expected for a patient post CVA. This may include sensory impairment to touch, loss of proprioception, difficulty interpreting visual, tactile, and auditory stimuli.

Option D: Depression and anxiety are common responses by a patient after a catastrophic event such as in stroke. Emotional lability (or pseudobulbar affect), refers to the involuntary and uncontrollable bursts of emotion without an emotional trigger.

---