The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?
Facial droop
Dysrhythmias
Periorbital edema
Projectile vomiting .
The Correct Answer is A
Choice A rationale
Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.
Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Ascending muscle weakness is a classic symptom of Guillain-Barre syndrome. It often starts in the feet and legs before spreading to the upper body and arms.
Choice B rationale
Difficulty with urination is not a typical symptom of Guillain-Barre syndrome.
Choice C rationale
Ptosis (drooping of the upper eyelid) and diplopia (double vision) are not common symptoms of Guillain-Barre syndrome.
Choice D rationale
Ear distortion and pain are not associated with Guillain-Barre syndrome.
Correct Answer is B
Explanation
Choice A rationale
Instilling mineral oil into the canal and immediately irrigating to remove the impacted wax is not typically recommended. This approach may not allow enough time for the mineral oil to soften the cerumen, making it more difficult to remove and potentially causing discomfort or injury.
Choice B rationale
Instilling a small amount of mineral oil into the canal, then having the patient return in 30 minutes for wax removal is a common and effective method for managing cerumen impaction. The mineral oil helps to soften the cerumen, making it easier to remove through irrigation.
Choice C rationale
Irrigating the ear with cold water is not typically recommended. Cold water can cause discomfort and potentially lead to vertigo.
Choice D rationale
Irrigating the ear with warm water and a high amount of otic pressure is not typically recommended. High pressure can potentially damage the ear canal or tympanic membrane.
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