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. Asthma exacerbation typically causes wheezing or bronchospasm and would not usually cause decreased breath sounds in one lung.
B. Pulmonary embolism may cause breathlessness or decreased oxygen levels, but it wouldn't typically cause unilateral decreased breath sounds.
C. Pneumothorax is the most likely cause, as air in the pleural space can collapse the lung, leading to decreased or absent breath sounds on the affected side.
D. Pulmonary edema typically causes bilateral crackles and would not cause unilateral decreased breath sounds.

A. Top-to-bottom comparison B. Posterior-to-anterior comparison C. Interspace-by-interspace comparison D. Side-to-side comparison

Correct Answer is D

Explanation

A. Top-to-bottom comparison is not the best method for auscultation. A more systematic approach is needed.
B. Posterior-to-anterior comparison does not apply to all auscultation areas, and a consistent method across the thorax is preferred.
C. Interspace-by-interspace comparison involves comparing sounds across different intercostal spaces but is not a method for transitioning between sites.
D. Side-to-side comparison ensures the nurse is assessing both sides of the thorax equally and systematically, which is the correct approach.

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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

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