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. Peripheral vascular disease involves issues with blood flow to the extremities but does not typically present with jugular vein distension or a gallop heart sound.
B. Fluid and electrolyte disturbances may affect heart rhythm and fluid balance but are less likely to present with these specific findings.
C. Heart failure is the most likely cause, as jugular vein distension and a third heart sound (S3 gallop) are common signs of heart failure, particularly when the heart cannot effectively pump blood.
D. Atrial-septal defect may cause heart murmurs or irregular rhythms but is not typically associated with jugular vein distension or an S3 gallop.

A. When adventitious sounds are present B. When the bronchial tree is obstructed C. In conjunction with whispered pectoriloquy D. In conditions of consolidation, such as pneumonia

Correct Answer is B

Explanation

A. Adventitious sounds (e.g., wheezing, crackles, or stridor) are abnormal sounds that may be heard in addition to breath sounds. They do not specifically correlate with decreased breath sounds.
B. When there is obstruction in the bronchial tree (such as in conditions like asthma, chronic obstructive pulmonary disease (COPD), or a foreign body obstruction), the airflow is reduced, leading to decreased breath sounds in the affected areas.
C. Whispered pectoriloquy refers to hearing whispered sounds through the stethoscope, which would be more clearly heard with consolidation or lung tissue becoming more solid (e.g., in pneumonia), not with decreased breath sounds.
D. In consolidation (such as pneumonia), breath sounds are typically increased or bronchial, not decreased. The consolidation makes the lung tissue more solid, which can amplify breath sounds.

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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?

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Naxlex Comprehensive Predictor Exams

During a cardiac assessment of a client you observed jugular vein distension, and auscultated $3 gallop heart sound. These findings most likely suggest which of the following conditions?

Correct Answer is C

Explanation

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

Correct Answer is B

Explanation

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