The nurse is caring for an older adult client who has recently had a stroke. The nurse assesses that the right side of the client's face is drooping. The nurse might also expect which of the following assessment findings?

Xerostomia

Epistaxis

Dysphagia

Rhinorrhea

Answer and Explanation

The Correct Answer is C

A. Xerostomia: Xerostomia refers to dry mouth, which is caused by reduced saliva production. While it can be a symptom of various conditions, it is not directly associated with facial drooping after a stroke.

B. Epistaxis: Epistaxis is a medical term for a nosebleed. It occurs due to the rupture of small, delicate blood vessels within the nose. While it can happen independently of a stroke, it is not directly related to facial drooping caused by a stroke.

C. Dysphagia: Dysphagia refers to difficulty in swallowing, which can occur after a stroke due to muscle weakness, including the facial muscles. Facial drooping on one side can be indicative of stroke-related muscle weakness and can contribute to difficulties in swallowing.

D. Rhinorrhea: Rhinorrhea is the medical term for a runny nose, where the nasal cavity is filled with a significant amount of mucus. It is usually caused by various factors such as allergies, infections, or irritants. Rhinorrhea is not directly associated with facial drooping after a stroke.

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Correct Answer is C

Explanation

A. Friction rub:

A friction rub is a grating or rubbing sound or sensation heard or felt during auscultation or palpation. It occurs when inflamed pleural or pericardial surfaces rub against each other during breathing or heartbeats, respectively.

B. Tactile fremitus:

Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks. It is assessed by placing hands on the patient's back while the patient speaks certain words. Increased tactile fremitus can occur in conditions with lung consolidation, such as pneumonia.

C. Crepitus:

Crepitus is a crackling or grating sensation felt under the skin or heard when the ends of a broken bone rub against each other. It can also occur when air leaks into subcutaneous tissue, leading to a crackling sensation upon palpation.

D. Adventitious sounds:

Adventitious sounds refer to abnormal lung sounds heard during auscultation. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. Adventitious sounds can indicate various respiratory conditions, such as pneumonia, bronchitis, or asthma.

A. Xiphoid process. B. Suprasternal notch. C. Sternal angle. D. Costal angle.

Correct Answer is C

Explanation

A. Xiphoid process:

The xiphoid process is a small, cartilaginous extension at the inferior end of the sternum (breastbone). It does not play a role in the bifurcation of the trachea.

B. Suprasternal notch:

The suprasternal notch, also known as the fossa jugularis sternalis or jugular notch, is the visible dip in the superior part of the manubrium of the sternum between the clavicular notches. It is an important anatomical landmark for assessing the position of the trachea during emergency situations but is not the location of tracheal bifurcation.

C. Sternal angle (Angle of Louis):

The sternal angle, or Angle of Louis, is a palpable notch located at the articulation of the manubrium and the body of the sternum. It is where the second rib attaches and serves as a useful reference point for counting ribs and locating internal structures like the tracheal bifurcation.

D. Costal angle:

The costal angle is the acute angle formed by the junction of the costal margins at the xiphoid process. It is not related to the tracheal bifurcation.

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The nurse is caring for an older adult client who has recently had a stroke. The nurse assesses that the right side of the client's face is drooping. The nurse might also expect which of the following assessment findings?

Nursing Test Bank

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Correct Answer is C

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Correct Answer is C

Explanation

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