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
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 C
Explanation
Choice A rationale
Assessing lung sounds is an important part of monitoring a patient’s respiratory status, but it may not be the most immediate action if the patient is finding it increasingly difficult to breathe.
Choice B rationale
While explaining the progression of the syndrome is important for patient education, it may not be the most immediate action if the patient is experiencing difficulty breathing.
Choice C rationale
Guillain-Barre syndrome can affect the muscles used for breathing, resulting in a weakened or paralyzed diaphragm, which can lead to an ineffective breathing pattern. Therefore, if a patient states that it is getting harder to take a deep breath, the nurse should call the physician and prepare for possible intubation.
Choice D rationale
Encouraging the client to cough may not be the most appropriate action if the patient is finding it increasingly difficult to breathe.
Correct Answer is A
Explanation
Choice A rationale
Status epilepticus is a medical emergency characterized by continuous or rapid-fire seizures. Intravenous diazepam is one of the first-line treatments for this condition. It works by enhancing the effect of gamma-aminobutyric acid (GABA), a neurotransmitter that inhibits brain activity, thereby helping to stop the seizure.
Choice B rationale
Oral lorazepam is not typically used to halt a seizure immediately due to its slower onset of action compared to intravenous administration.
Choice C rationale
Oral phenytoin is not typically used to halt a seizure immediately. It is more commonly used for the long-term management of seizures.
Choice D rationale
Intravenous phenobarbital is a second-line treatment for status epilepticus, used when first- line treatments such as diazepam are ineffective.
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