A nurse is assisting with the care of a client who had a stroke.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Temperature 38 °C (100.4 °F)
- Bilateral breath sounds with wheezing heard in upper lobes.
- Oxygen saturation 88% on room air
Mucous membranes pink, skin warm and dry.
Coughing and clearing throat when eating.
Voice hoarse after swallowing.
Temperature 38 °C (100.4 °F)
Bilateral breath sounds with wheezing heard in upper lobes.
Oxygen saturation 88% on room air
The Correct Answer is ["B","C","D","E","F"]
- Mucous membranes pink, skin warm and dry.
- Coughing and clearing throat when eating.
- Voice hoarse after swallowing.
- Temperature 38 °C (100.4 °F)
- Bilateral breath sounds with wheezing heard in upper lobes.
- Oxygen saturation 88% on room air
Rationale
Coughing and clearing throat when eating: This indicates potential dysphagia (difficulty swallowing), which increases the risk of aspiration pneumonia—a serious complication post-stroke.
Voice hoarse after swallowing: Hoarseness or voice changes can also signal impaired swallowing or aspiration risk, necessitating evaluation by a speech therapist or further swallowing studies.
Temperature 38.5°C (101.3°F): An elevated temperature may suggest infection (e.g., aspiration pneumonia or another complication) and warrants further investigation, particularly in a post-stroke client.
Bilateral breath sounds with wheezing heard in upper lobes: Wheezing could indicate an airway obstruction, aspiration, or developing respiratory compromise, which is critical in this population.
Oxygen saturation 88% on room air: Hypoxemia is a critical finding requiring immediate intervention, such as supplemental oxygen and investigation into the underlying cause (e.g., aspiration, infection, or pulmonary embolism).
Mucous membranes pink, skin warm and dry: These findings are within normal limits and do not indicate a pressing issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Vitamin A deficiency can cause vision impairments, such as night blindness, due to its essential role in maintaining the health of the retina.
B. A swollen tongue is more commonly associated with vitamin B deficiencies, particularly riboflavin (B2) or niacin (B3).
C. Constipation is not a typical symptom of vitamin A deficiency and is more commonly linked to inadequate dietary fiber or dehydration.
D. Bleeding gums are associated with vitamin C deficiency, which impacts collagen synthesis and gum health, rather than vitamin A deficiency.
Correct Answer is B
Explanation
A. Keratinocytes are the most abundant cells in the epidermis, responsible for producing keratin, which strengthens skin but does not determine skin color.
B. Melanocytes produce melanin, the pigment responsible for skin color. They play a key role in protecting the skin from ultraviolet radiation.
C. Merkel cells are mechanoreceptors involved in touch sensation and do not influence pigmentation.
D. Langerhans cells are part of the immune system, aiding in the detection and presentation of pathogens, with no role in pigmentation.
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