A nurse is caring for a client who has had a stroke.
Select the 3 findings that require immediate follow-up.
Drooling
Blood pressure at 1800
Breath sounds at 1000
Hoarse voice
Temperature at 1800
Correct Answer : A,D,E
A. Drooling
Drooling can be concerning due to impaired swallowing and risk of aspiration.
D. Hoarse voice
Hoarseness after swallowing can indicate aspiration, which is a serious complication for stroke patients due to difficulty swallowing.
E. Temperature at 1800
A temperature of 39.6°C (103.3°F) is significantly elevated and suggests a potential infection, which is a serious complication after a stroke
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. If there is no change in muscle strength after the Tensilon test, it indicates a negative result for myasthenia gravis.
B. Muscle contractions become progressively stronger is a positive result for myasthenia gravis. Tensilon temporarily improves muscle strength in patients with this condition.
C. Electrical charge in a muscle increases in intensity is not a relevant parameter for the Tensilon test.
D. A pill-rolling tremor appears is a symptom of Parkinson's disease, not myasthenia gravis.
Correct Answer is B
Explanation
A. Pupils round, 2mm and constricting to light is a normal pupil response.
B. Decreasing level of consciousness is a critical sign of deteriorating neurological status and requires immediate medical intervention.
C. Temporal headache is a common symptom after head injury but it is not as urgent as a decreasing level of consciousness.
D. Glasgow coma score of 13 indicates a mild to moderate head injury, but it's a static measurement. A decreasing level of consciousness would indicate worsening condition.
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