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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Perform the confrontation test:
The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.
B. Ask the patient to read the print on a handheld Jaeger card:
Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.
C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:
This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.
D. Use the Snellen chart positioned 20 feet away from the patient:
The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.
Correct Answer is C
Explanation
A. Fifth intercostal space, left of the midclavicular line: This placement is used to auscultate the mitral valve, which is best heard at the apex of the heart. The mitral valve sounds are typically heard around the fifth intercostal space, midclavicular line.
B. Left lower sternal border: This placement is used to auscultate the tricuspid valve, which is best heard at the lower left sternal border.
C. Second left intercostal space: This is the correct placement for auscultating the pulmonic valve. The pulmonic valve sounds are best heard at the second left intercostal space, which is close to the upper left sternal border.
D. Second right intercostal space: This placement is used to auscultate the aortic valve, which is best heard at the second right intercostal space, close to the upper right sternal border.

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