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

Explanation

Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale

Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.

A. Have the patient lie flat for 6 hours. B. Have the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees. C. Early ambulation. D. Have the patient lie flat for 1 hour, then sit up for 1 hour before ambulating.

Correct Answer is A

Explanation

Choice A rationale
After a lumbar puncture, it is important for the patient to lie flat for approximately 6 hours. This position helps to prevent headaches that can occur after the procedure, which are caused by leakage of cerebrospinal fluid at the needle puncture site. Lying flat allows the puncture site to seal and prevents the leakage of cerebrospinal fluid.
Choice B rationale
Having the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees is not typically recommended immediately after a lumbar puncture. This position could potentially increase the risk of a post-lumbar puncture headache.
Choice C rationale
Early ambulation is not recommended after a lumbar puncture. Moving around too soon after the procedure can increase the risk of a headache and may also increase the risk of complications at the puncture site.
Choice D rationale
Having the patient lie flat for 1 hour, then sit up for 1 hour before ambulating is not a typical recommendation after a lumbar puncture. The standard recommendation is to have the patient lie flat for approximately 6 hours to reduce the risk of complications.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

Correct Answer is D

Explanation

A patient is having 20 mL of cerebral spinal fluid removed via a lumbar puncture. What intervention is important after the procedure?

Correct Answer is A

Explanation

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