A nurse is caring for a client who has had a stroke. id assesses right-sided facial drooping. The nurse should also anticipate which of the following assessment findings?

Dysphagia

Rhinitis

Xerostomia

Epistaxis

Answer and Explanation

The Correct Answer is A

A. Dysphagia:
Dysphagia, or difficulty swallowing, is a common issue in clients who have had a stroke, particularly when there is facial drooping or weakness on one side of the face, which can affect the muscles involved in swallowing. A stroke can cause motor impairment, affecting the coordination and strength required for effective swallowing. This condition increases the risk of aspiration (food or liquid entering the airway), which can lead to respiratory complications such as pneumonia. It is crucial to assess for dysphagia in stroke patients and provide appropriate interventions, such as speech therapy and modified diets, to ensure safe swallowing.

B. Rhinitis:
Rhinitis, which refers to inflammation of the nasal passages causing symptoms like congestion, sneezing, and runny nose, is not directly related to stroke. Although rhinitis can be caused by allergies, infections, or environmental irritants, it is not a typical finding following a stroke. The presence of facial drooping on one side is more suggestive of a neurological issue affecting motor control, rather than an issue with the nasal passages or upper respiratory system.

C. Xerostomia:
Xerostomia, or dry mouth, can occur for various reasons, such as medication side effects or dehydration, but it is not a primary concern directly associated with stroke-induced facial drooping. While facial nerve dysfunction can affect salivation (since the facial nerve helps control the salivary glands), dysphagia and facial drooping are more immediate concerns for stroke patients. Xerostomia may occur in some cases, but it is not as directly linked to stroke as dysphagia is.

D. Epistaxis:
Epistaxis, or nosebleeds, is not a typical complication of stroke and is not associated with facial drooping. While certain factors like dry air, medications (e.g., anticoagulants), or trauma could cause nosebleeds, they are not common findings directly related to a stroke. The focus should be on potential neurological deficits, such as difficulty swallowing, impaired speech, or weakness, rather than epistaxis.

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Correct Answer is A

Explanation

A) The partner places the client's arm above the level of the client's heart:
This action indicates that further instruction is needed. For an accurate blood pressure reading, the arm should be at heart level (approximately at the level of the fourth intercostal space) when taking the measurement. If the arm is placed above the heart, it can result in a falsely low reading. If the arm is positioned below the heart, it can lead to a falsely high reading. The position of the arm is crucial for obtaining an accurate blood pressure measurement.

B) The partner centres the cuff bladder over the client's brachial artery:
This is the correct technique. The cuff bladder should be centered over the brachial artery for accurate readings. Proper cuff placement ensures the best possible measurement and avoids errors in reading due to misplacement.

C) The partner wraps the blood pressure cuff around the client's arm using firm pressure:
This is also correct. The cuff should be wrapped snugly around the upper arm with firm pressure to ensure that it fits properly. If the cuff is too loose or too tight, it may give inaccurate readings. However, it should never be excessively tight.

D) The partner checks the instrument gauge to ensure the reading starts at zero:
This is a correct action. Before using a blood pressure cuff, it is important to check that the gauge starts at zero when the cuff is deflated. This ensures the manometer is calibrated properly and provides accurate readings. If the gauge does not start at zero, it should be recalibrated or replaced.

A. Lid lag when moving the eyes from a superior to an inferior position B. Nystagmus when reading the Snellen chart C. Parallel movement of both eyes D. Convergence of the eyes

Correct Answer is C

Explanation

A) Lid lag when moving the eyes from a superior to an inferior position:
This is incorrect. Lid lag refers to a delay in the movement of the eyelid as the eyes move downward. It is considered an abnormal finding and is often associated with conditions like hyperthyroidism (Graves' disease), where the eyelid does not follow the downward gaze appropriately. In the diagnostic positions test, normal eye movement should not include lid lag.

B) Nystagmus when reading the Snellen chart:
This is incorrect. Nystagmus is an involuntary, rhythmic oscillation of the eyes, which can be indicative of a neurological or vestibular issue. It is not a normal finding during the diagnostic positions test. Nystagmus may be seen with certain disorders, such as vestibular dysfunction, neurologic damage, or alcohol intoxication, but it should not occur as a normal response to eye movement during the diagnostic positions test.

C) Parallel movement of both eyes:
This is the correct answer. In a normal result of the diagnostic positions test, both eyes should move in parallel and remain aligned during all directions of gaze. The purpose of this test is to assess for any eye muscle weakness or cranial nerve dysfunction that might cause misalignment, such as strabismus or a disorder affecting the extraocular muscles. If both eyes track smoothly and simultaneously without deviation or lag, this is a normal and expected finding.

D) Convergence of the eyes:
This is incorrect. While convergence (the inward movement of both eyes toward the nose) is a normal response when focusing on a near object, it is not the specific goal of the diagnostic positions test. The diagnostic positions test is primarily concerned with assessing the ability of the eyes to move together in all directions of gaze without misalignment or abnormal movement. While convergence is a sign of normal eye function, it is not the primary focus of this particular test.

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A nurse is caring for a client who has had a stroke. id assesses right-sided facial drooping. The nurse should also anticipate which of the following assessment findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner should indicate that further instruction is needed?

Correct Answer is A

Explanation

A nurse is performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?

Correct Answer is C

Explanation

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