The nurse is assessing a client with a suspected stroke. What assessment finding is most suggestive of a stroke?
Projectile vomiting
Periorbital edema
Facial droop
Dysrhythmias
The Correct Answer is C
A. Projectile vomiting: While vomiting can occur in conditions involving increased intracranial pressure, it is not specific to stroke and can be seen in various other medical conditions such as gastrointestinal illness or brain tumors.
B. Periorbital edema: Swelling around the eyes is usually linked to allergic reactions, kidney disorders, or fluid retention. It is not associated with stroke and does not indicate cerebral dysfunction.
C. Facial droop: Facial droop is a hallmark sign of a stroke, often resulting from weakness or paralysis of the facial muscles on one side due to impaired blood flow to the brain. It is a key indicator assessed in stroke screening tools like FAST.
D. Dysrhythmias: Although dysrhythmias like atrial fibrillation increase the risk of embolic stroke, they are not direct signs of an active stroke event. They are a contributing factor rather than a diagnostic symptom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Avoiding brushing the teeth: Maintaining oral hygiene is essential, even with Bell palsy. The client should continue to brush their teeth carefully to prevent dental problems and infections. Avoiding brushing could increase the risk of oral health issues.
B. Applying a protective eye shield at night: Bell palsy can cause incomplete eyelid closure, increasing the risk of corneal dryness and injury. Using an eye shield or patch during sleep protects the eye from irritation and trauma, preventing complications like corneal ulcers.
C. Chewing on the affected side to prevent unilateral neglect: Chewing on the affected side is not recommended as it can increase the risk of injury due to reduced muscle control. Clients should be advised to chew on the unaffected side to avoid biting the cheek or tongue.
D. Avoiding the use of analgesics whenever possible: Pain management is important in Bell palsy, as clients often experience facial pain or discomfort. Appropriate analgesics should be used as needed to maintain comfort and promote recovery.
Correct Answer is C
Explanation
A. Projectile vomiting: While vomiting can occur in conditions involving increased intracranial pressure, it is not specific to stroke and can be seen in various other medical conditions such as gastrointestinal illness or brain tumors.
B. Periorbital edema: Swelling around the eyes is usually linked to allergic reactions, kidney disorders, or fluid retention. It is not associated with stroke and does not indicate cerebral dysfunction.
C. Facial droop: Facial droop is a hallmark sign of a stroke, often resulting from weakness or paralysis of the facial muscles on one side due to impaired blood flow to the brain. It is a key indicator assessed in stroke screening tools like FAST.
D. Dysrhythmias: Although dysrhythmias like atrial fibrillation increase the risk of embolic stroke, they are not direct signs of an active stroke event. They are a contributing factor rather than a diagnostic symptom.
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.
