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 C

Explanation

A. Improper positioning does not apply in this case; the position described is often associated with respiratory distress.
B. Fatigue or weakness may be present, but the described position is more indicative of difficulty breathing.
C. Respiratory distress is suggested by the patient leaning forward, which is a common position for patients with shortness of breath as it helps expand the lungs and ease breathing.
D. Increased comfort and relaxation is unlikely; this position is more often associated with discomfort and difficulty breathing.

A. Increasing capillary fragility B. increased sebaceous and sweat glands. C. Decreased collagen. D. Lose elasticity

Correct Answer is C

Explanation

A. Increasing capillary fragility contributes to bruising and bleeding but does not directly cause skin folding or sagging.
B. Increased sebaceous and sweat glands may affect skin texture but are not the primary cause of sagging skin.
C. Decreased collagen is the primary reason for skin sagging in aging, as collagen provides structure and elasticity to the skin. With age, collagen production decreases, leading to wrinkles and sagging.
D. Loss of elasticity is a consequence of reduced collagen and elastin fibers, contributing to skin changes, but decreased collagen is the main cause of the sagging.

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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

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