A nurse is caring for a client who recently had a stroke. Which alteration in neurologic function should the nurse expect?

Facial drooping

Frequent diarrhea

Steady gait

Vocal clarity

Answer and Explanation

The Correct Answer is A

A. Facial drooping is a common symptom following a stroke, particularly if it affects areas of the brain responsible for facial movement.

B. Frequent diarrhea is not typically associated with stroke and may be related to other factors.

C. A steady gait is unlikely following a stroke, especially if the stroke has affected motor control or balance.

D. Vocal clarity can be affected after a stroke, but facial drooping is a more immediate and recognizable alteration in neurologic function.

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Correct Answer is ["A","C","D"]

Explanation

A. PICC line insertion site: The client reports pain, redness, and edema at the PICC line insertion site, which are signs of a possible infection. This finding requires immediate follow-up to prevent complications like bloodstream infection or sepsis.

B. Breath sounds: The client’s breath sounds are clear and unchanged from Day 1, so this finding does not require immediate follow-up.

C. Temperature: The client's temperature has risen to 39 °C (102.2 °F) from 37.2 °C (99 °F) on Day 1. Such a significant increase in temperature indicates a possible infection and needs prompt intervention.

D. Heart rate: The client’s heart rate has increased to 108/min from 66/min, suggesting tachycardia. This could be a response to infection, potentially linked to sepsis, and warrants immediate follow-up.

E. Albumin level: The albumin level has increased to within the normal range, which is a positive trend and does not require urgent intervention.

A. Response to verbal stimuli B. Affect, feelings, or emotions C. Eye movements D. Insight, judgment, and planning

Correct Answer is C

Explanation

A. Response to verbal stimuli does not directly assess the function of cranial nerves III, IV, and VI.

B. Affect, feelings, or emotions are related to the assessment of other neurological functions and do not evaluate the ocular cranial nerves specifically.

C. Eye movements are the primary function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye movement and provide essential information about their function.

D. Insight, judgment, and planning relate more to cognitive function and do not directly assess the function of the cranial nerves in question.

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A nurse is caring for a client who recently had a stroke. Which alteration in neurologic function should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select the 3 findings on day 3 that require immediate follow-up. Exhibits

Correct Answer is ["A","C","D"]

Explanation

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves?

Correct Answer is C

Explanation

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