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 ["A","D","E"]
Explanation
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
Correct Answer is C
Explanation
A. Sedatives would further depress the respiratory muscles, worsening the myasthenic crisis.
B. Instruct the client to perform pursed lip breathing can be helpful for managing dyspnea in other conditions. However, it's not the priority in a myasthenic crisis where respiratory muscles are rapidly weakening.
C. As respiratory muscles weaken in a myasthenic crisis, the patient is at risk for respiratory failure. Preparing for mechanical ventilation is crucial.
D. A vasoconstrictor is used to treat shock, not a myasthenic crisis.
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