Stroke Warning signs includes? Select all that applied.

Kernig sign

Arm Weakness

Sudden confusion or trouble understanding

Face Drooping

negative Babinski reflex

Speech Difficulty

Answer and Explanation

Correct Answer : B,C,D

A.   The Kernig sign is a clinical test used to diagnose meningitis, not stroke. It involves flexing the patient’s hip and knee and then attempting to extend the knee while the hip is flexed. Pain or resistance during this maneuver can suggest meningeal irritation.
B.   Arm weakness refers to the loss of strength or control in one or both arms, which can be a sign of a stroke. It may be noticeable when a person is unable to lift their arm or keep it raised.
C.   Sudden confusion, trouble understanding, or difficulty speaking can be signs of a stroke. This may involve problems with language or comprehension, which are related to the areas of the brain responsible for these functions.
D.   Face drooping, especially on one side of the face, is a classic sign of stroke. It occurs when the muscles on one side of the face weaken or become paralyzed.
E.   The Babinski reflex is a test where the sole of the foot is stroked, and the normal response in adults is the downward flexion of the toes. An abnormal Babinski reflex (upward extension of the big toe) can indicate neurological problems but is not a specific warning sign of stroke.
F.   Speech difficulty, such as slurred speech or trouble finding words, is a common sign of a stroke. It can involve problems with articulation, coherence, or understanding language.

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Correct Answer is D

Explanation

A. The trigeminal nerve (CN V) is primarily responsible for sensation in the face and the motor control of the muscles used for chewing. It does not have a role in balance or equilibrium, so it would not be the focus when assessing balance issues.
B. The facial nerve (CN VII) controls the muscles of facial expression and provides taste sensation to the anterior two-thirds of the tongue. While it plays a significant role in facial movement and taste, it is not involved in balance or equilibrium.
C. The olfactory nerve (CN I) is responsible for the sense of smell. It does not have any role in balance or equilibrium. Balance issues are not related to the olfactory nerve, so this is not the appropriate focus for balance assessment.
D. The vestibulocochlear nerve (CN VIII) has two major components: the cochlear nerve, which is responsible for hearing, and the vestibular nerve, which is responsible for balance and equilibrium. The vestibular component of CN VIII is crucial for maintaining balance and spatial orientation. When a client reports spontaneous loss of balance, this nerve should be the focus of additional assessment.

A. Coma B. Stupor C. Lethargy D. Obtunded

Correct Answer is D

Explanation

A. Coma is a state of profound unconsciousness where the patient cannot be awakened and does not respond to any external stimuli. The patient is completely unresponsive, with no eye opening or verbal responses.
B. Stupor is a state where the patient is almost completely unresponsive and can only be awakened by vigorous or painful stimuli. When aroused, they may only give brief, non-purposeful responses.
C. Lethargy is characterized by drowsiness and decreased alertness. The patient may fall asleep easily but can be awakened and will respond appropriately to stimuli. They might appear sluggish or tired.
D. Obtunded refers to a state where the patient has a reduced level of consciousness and responsiveness. They may be difficult to arouse, respond slowly to stimuli, and have a dulled sense of awareness. They need increased stimulation to achieve a response.

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Stroke Warning signs includes? Select all that applied.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?

Correct Answer is D

Explanation

In the Neuro ICU (intensive care unit) while performing a neurological assessment of the patient the nurse noticed the patient: patient opens eyes, looks at you, responds slowly, and is somewhat confused. What level of consciousness (LOC) is this patient presenting?

Correct Answer is D

Explanation

Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

A client is able to actively move the right arm against gravity. How should the nurse document this finding using the muscle strength grading?

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

During an assessment, the nurse asks a client to explain what the following means: "A penny saved is a penny earned." The nurse is assessing which of the following?

A patient that is Comatose based on the Level of Consciousness (LOC) assessment using the Glasgow Coma scale is in what numeric range of the scale?

A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? Select all that apply.

The nurse places a coin in the patient's hand, the patient is with eyes closed. The ability to identify an object by feeling it is defined as:

Which of the following would the nurse most likely expect to find when assessing a client diagnosed with a frontal lobe contusion (in the Broca's Area) following a motor vehicle accident?