A nurse is caring for a client who has had a stroke. id assesses right-sided facial drooping. The nurse should also anticipate which of the following assessment findings?

Dysphagia

Rhinitis

Xerostomia

Epistaxis

Answer and Explanation

The Correct Answer is A

A. Dysphagia:
Dysphagia, or difficulty swallowing, is a common issue in clients who have had a stroke, particularly when there is facial drooping or weakness on one side of the face, which can affect the muscles involved in swallowing. A stroke can cause motor impairment, affecting the coordination and strength required for effective swallowing. This condition increases the risk of aspiration (food or liquid entering the airway), which can lead to respiratory complications such as pneumonia. It is crucial to assess for dysphagia in stroke patients and provide appropriate interventions, such as speech therapy and modified diets, to ensure safe swallowing.

B. Rhinitis:
Rhinitis, which refers to inflammation of the nasal passages causing symptoms like congestion, sneezing, and runny nose, is not directly related to stroke. Although rhinitis can be caused by allergies, infections, or environmental irritants, it is not a typical finding following a stroke. The presence of facial drooping on one side is more suggestive of a neurological issue affecting motor control, rather than an issue with the nasal passages or upper respiratory system.

C. Xerostomia:
Xerostomia, or dry mouth, can occur for various reasons, such as medication side effects or dehydration, but it is not a primary concern directly associated with stroke-induced facial drooping. While facial nerve dysfunction can affect salivation (since the facial nerve helps control the salivary glands), dysphagia and facial drooping are more immediate concerns for stroke patients. Xerostomia may occur in some cases, but it is not as directly linked to stroke as dysphagia is.

D. Epistaxis:
Epistaxis, or nosebleeds, is not a typical complication of stroke and is not associated with facial drooping. While certain factors like dry air, medications (e.g., anticoagulants), or trauma could cause nosebleeds, they are not common findings directly related to a stroke. The focus should be on potential neurological deficits, such as difficulty swallowing, impaired speech, or weakness, rather than epistaxis.

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Correct Answer is C

Explanation

A) Daily, during the shower or bath:
This is incorrect. Performing a breast self-examination (BSE) daily is not necessary. The goal of BSE is to check for any changes over time, not to examine the breasts every day. It's more effective to perform the exam regularly at a consistent time each month.

B) One week after the menstrual period:
This is incorrect. This instruction is relevant for pre-menopausal women, where the hormonal changes associated with the menstrual cycle can cause breast tissue to feel lumpy or swollen. The best time for them to perform a BSE is one week after the menstrual period ends when the breasts are least likely to be swollen or tender. However, for postmenopausal women, this is not necessary, as their hormonal levels are stable throughout the month.

C) On the same day every month:
This is the correct answer. For postmenopausal women, who no longer have menstrual cycles, the best time to perform a breast self-exam is on the same day every month. This ensures consistency and makes it easier for the client to notice any changes in the breast tissue over time. The day chosen should be one that is convenient and easy to remember, and it does not matter whether it is during the shower or bath, as long as the examination is done regularly.

D) Weekly, at the client's convenience:
This is incorrect. While performing a BSE weekly is not necessary, the key is consistency rather than frequency. Performing the exam monthly is sufficient, and it should be on a specific day each month, rather than at the client’s convenience on an irregular basis.

A. Use the Snellen chart positioned 20 feet away from the client B. Determine the client’s ability to read newsprint at a distance of 12 to 14 inches C. Perform the confrontation test D. Ask the client to read the print on a handheld jaeger card

Correct Answer is A

Explanation

A) Use the Snellen chart positioned 20 feet away from the client:
This is the correct method for assessing visual acuity in adults. The Snellen chart is the standard tool used to measure visual acuity at a distance. The client is positioned 20 feet away from the chart, and they are asked to read the smallest line of letters they can clearly identify. The result is typically documented as a fraction (e.g., 20/20), where the numerator represents the distance from the chart, and the denominator represents the distance at which a person with normal vision can read the same line. This test assesses distance vision and is essential for checking overall visual sharpness.

B) Determine the client’s ability to read newsprint at a distance of 12 to 14 inches:
This is not used to assess visual acuity; it assesses near vision and can be part of the overall vision examination, but it is not the standard method for testing visual acuity. Typically, the near vision assessment is done with tools like a Jaeger chart or by asking the client to read newsprint at a standard reading distance (12 to 14 inches), but this is not the primary test for visual acuity. The Snellen chart is specifically for distance vision.

C) Perform the confrontation test:
The confrontation test is used to assess the visual fields, not visual acuity. It is a quick screening to determine if the client has any peripheral vision loss, where the nurse and the client compare their visual fields by covering one eye at a time and identifying moving fingers in the periphery. While important, this test does not assess the sharpness or clarity of central vision, which is the focus of a visual acuity test.

D) Ask the client to read the print on a handheld Jaeger card:
The Jaeger card is used to assess near vision, not visual acuity. It is used for clients who may have difficulty reading small print at a normal reading distance and helps assess presbyopia (difficulty focusing on near objects with age). However, this test is for near vision and is not the primary test for visual acuity, which typically focuses on distance vision.

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A nurse is caring for a client who has had a stroke. id assesses right-sided facial drooping. The nurse should also anticipate which of the following assessment findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is discussing Breast Self Examination (BSE) with a postmenopausal client. What instructions should the nurse give to the client about the correct time to perform BSE?

Correct Answer is C

Explanation

A nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Correct Answer is A

Explanation

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