The nurse is conducting an assessment on a patient suspected of having a stroke. Which assessment finding is most indicative of a stroke?

Facial droop

Dysrhythmias

Periorbital edema

Projectile vomiting

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice B rationale
Patients who experience severe cluster headaches should be instructed to take medications as soon as they sense the onset of symptoms. Cluster headaches are characterized by severe, debilitating pain that reaches peak intensity within a short period of time, often within 15 minutes. Therefore, early intervention is crucial to manage the pain effectively.
Choice A rationale

Waiting twenty to thirty minutes after the onset of symptoms to take medications may not be effective for cluster headaches. The pain of a cluster headache often reaches peak intensity within 15 minutes, so delaying medication could result in unnecessary suffering.
Choice C rationale
Waiting until the patient’s pain becomes unbearable is not recommended for managing cluster headaches. The goal of treatment is to prevent or reduce pain, not to wait until it becomes unbearable.
Choice D rationale
Taking medications when the patient senses their symptoms are peaking is not the most effective strategy for managing cluster headaches. Given the rapid onset and severe pain associated with cluster headaches, medications should be taken as soon as the patient senses the onset of symptoms.

A. Instruct the client on daily muscle stretching. B. Order a low-residual diet. C. Encourage the client to void every hour. D. Provide total assistance with all activities of daily living.

Correct Answer is A

Explanation

Choice A rationale
Instructing the client on daily muscle stretching can help alleviate and relax muscle spasms, which is beneficial for a client diagnosed with multiple sclerosis.

Choice B rationale
Ordering a low-residual diet is not typically a part of the care plan for a client diagnosed with multiple sclerosis.
Choice C rationale
Encouraging the client to void every hour may not be necessary for a client diagnosed with multiple sclerosis, unless there are specific urinary symptoms present.
Choice D rationale
Providing total assistance with all activities of daily living may not be necessary for a client diagnosed with multiple sclerosis, as the level of assistance required can vary greatly depending on the severity of the disease.

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The nurse is conducting an assessment on a patient suspected of having a stroke. Which assessment finding is most indicative of a stroke?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who experiences severe cluster headaches. At what point in the course of a new headache should the patient be instructed to take medications?

Correct Answer is B

Explanation

The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client’s care plan?

Correct Answer is A

Explanation

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?

The nurse is conducting an assessment on a patient suspected of having a stroke. Which assessment finding is most indicative of a stroke?

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

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