A nurse is caring for a client who has had a stroke.
Select the 3 findings that require immediate follow-up.
Drooling
Blood pressure at 1800
Breath sounds at 1000
Hoarse voice
Temperature at 1800
Correct Answer : A,D,E
A. Drooling
Drooling can be concerning due to impaired swallowing and risk of aspiration.
D. Hoarse voice
Hoarseness after swallowing can indicate aspiration, which is a serious complication for stroke patients due to difficulty swallowing.
E. Temperature at 1800
A temperature of 39.6°C (103.3°F) is significantly elevated and suggests a potential infection, which is a serious complication after a stroke
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The normal P-R interval ranges from 0.12 to 0.20 seconds. A P-R interval longer than 0.20 seconds is considered prolonged and may indicate a first-degree AV block.
B. The T wave represents ventricular repolarization. Normally, the T wave is upright in most leads. An inverted T wave can indicate various conditions, including ischemia, electrolyte imbalances, or other abnormalities
C. The normal QRS duration ranges from 0.06 to 0.10 seconds. A QRS duration greater than 0.10 seconds indicates a delay in ventricular conduction, which could be due to a bundle branch block or other conduction abnormalities.
D. In a normal sinus rhythm, the P wave should consistently appear before each QRS complex. This reflects proper atrial depolarization followed by ventricular depolarization. This pattern indicates that the heart's electrical impulses are originating from the sinus node and are being properly conducted through the AV node to the ventricles.
Correct Answer is C
Explanation
A. Sedatives would further depress the respiratory muscles, worsening the myasthenic crisis.
B. Instruct the client to perform pursed lip breathing can be helpful for managing dyspnea in other conditions. However, it's not the priority in a myasthenic crisis where respiratory muscles are rapidly weakening.
C. As respiratory muscles weaken in a myasthenic crisis, the patient is at risk for respiratory failure. Preparing for mechanical ventilation is crucial.
D. A vasoconstrictor is used to treat shock, not a myasthenic crisis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.