A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

Xerostomia

Rhinorrhea

Dysphagia

Epistaxis

Answer and Explanation

The Correct Answer is C

A.   Xerostomia (dry mouth) is common in some conditions but not typically associated with a stroke.
B.   Rhinorrhea (runny nose) is not a typical finding related to stroke.
C.   Dysphagia (difficulty swallowing) is a common issue for patients after a stroke, especially if the stroke affects the areas of the brain responsible for swallowing.
D.   Epistaxis (nosebleed) is not a direct consequence of a stroke. The nurse should be more concerned with symptoms related to swallowing, speech, and motor function, such as dysphagia.

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Correct Answer is ["A","D","E","G"]

Explanation

A. Client's blood pressure is relevant as it can help correlate the murmur with potential cardiac conditions.
B. Client's weight is not directly related to documenting a heart murmur.
C. Client's respiratory rate is also not relevant to the murmur documentation unless respiratory symptoms are present.
D. Intensity of the murmur is important to document, as it helps assess the severity.
E. Location of the murmur is important for identifying which valve or area of the heart is involved.
F. Client's temperature is not directly related to documenting a heart murmur.
G. Timing of the murmur helps in identifying whether it occurs during systole or diastole, aiding in diagnosis.

A. Adrenal B. Parotid C. Thyroid D. Parathyroid

Correct Answer is C

Explanation

A. Adrenal: The adrenal glands produce hormones like cortisol and adrenaline, but not thyroxine.
B. Parotid: The parotid glands are salivary glands and are unrelated to thyroxine production.
C. Thyroid: The thyroid gland produces thyroxine (T4), and elevated levels of this hormone indicate that the thyroid gland should be assessed for potential hyperthyroidism.
D. Parathyroid: The parathyroid glands regulate calcium levels but do not produce thyroxine.

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A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

Correct Answer is ["A","D","E","G"]

Explanation

A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse assess?

Correct Answer is C

Explanation

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