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
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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Related Questions
Correct Answer is D
Explanation
A. Cervical nodes drain the head and neck area, not typically the forearm or hand.
B. Epitrochlear nodes are found near the elbow and are responsible for draining the arm. The nurse would assess these nodes if the infection is in the arm or hand.
C. Inguinal nodes drain the lower extremities and groin area, not the upper extremities.
D. Axillary nodes drain the upper limbs, including the forearm and hand, and are likely to be swollen if there is an infection in the upper extremities.
Correct Answer is B
Explanation
A. This is a vibration felt on the chest wall when a patient speaks, often used to assess lung sounds. It is not associated with the crackling sensation described here.
B. The coarse, crackling sensation felt on the skin surface when palpating is crepitus, which occurs when air escapes into the subcutaneous tissue, often due to trauma, infection, or the presence of a pneumothorax.
C. These are abnormal lung sounds, such as crackles, wheezes, or rhonchi, heard with a stethoscope during auscultation, not felt on the chest wall during palpation.
D. A friction rub is a grating or scraping sound heard with a stethoscope, typically due to inflammation of the pleural surfaces. It is not a sensation felt on the chest wall.
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