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 C
Explanation
A. Pacemaker spikes with each T wave indicates a malfunctioning pacemaker.
B. Pacemaker spikes before each P wave would indicate atrial pacing, not ventricular pacing.
C. A ventricular pacemaker stimulates the ventricles to contract, so the pacing spike should precede the QRS complex.
D. Pacemaker spikes after each QRS complex would indicate a malfunctioning pacemaker.
Correct Answer is A
Explanation
A. Lorazepam is a benzodiazepine used as the first-line treatment for status epilepticus. It rapidly terminates seizures.
B. A beta-blocker, atenolol is used for conditions like hypertension and angina, not for seizures.
C. While phenytoin is an anti-seizure medication, it has a slower onset of action compared to lorazepam. It's used as a second-line agent in status epilepticus.
D. Levetiracetam is an anti-epileptic drug, but not the first choice for acute seizure management like status epilepticus.
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