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 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.

A. Administering hydromorphone as needed B. Distracting the patient with activity C. Dimming the lights and reducing stimulation D. Initiating a patient-controlled analgesia (PCA) of morphine sulfate .

Correct Answer is C

Explanation

Choice C rationale
Dimming the lights and reducing stimulation can be an effective nursing intervention for a patient with herpes simplex virus encephalitis who is complaining of a headache. Bright lights and excessive noise can exacerbate headaches, so creating a quiet, dimly lit environment can help to alleviate this symptom.
Choice A rationale

While administering hydromorphone as needed can help to manage the patient’s pain, it does not directly address the patient’s complaint of a headache. Moreover, opioids like hydromorphone can have side effects such as drowsiness and constipation, which may not be desirable in a patient with encephalitis.
Choice B rationale
Distracting the patient with activity may not be appropriate for a patient with herpes simplex virus encephalitis who is complaining of a headache. Rest and quiet are often more beneficial for these patients.
Choice D rationale
Initiating a patient-controlled analgesia (PCA) of morphine sulfate can provide effective pain relief for some patients, but it may not be the best first-line approach for a patient with a headache due to herpes simplex virus encephalitis. Like hydromorphone, morphine can have side effects such as drowsiness and constipation.

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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

A nurse is caring for a client recently diagnosed with Guillain-Barre syndrome. The client states, “It is getting harder to take a deep breath.”. Which action by the nurse is most appropriate?

Correct Answer is C

Explanation

A patient is being admitted to the unit with suspected herpes simplex virus encephalitis. What nursing action best addresses the patient’s complaints of headache?

Correct Answer is C

Explanation

The nurse is educating a patient who has been newly prescribed eye medications to treat glaucoma. How can the nurse best determine if the patient can safely and effectively self-administer the medications?

A client with trigeminal neuralgia has been given suggestions to minimize episodes of pain. Which statement, if made by the client, would indicate the need for further teaching?

The nurse is caring for a patient suspected of having meningitis. After reviewing the lab results, which medication does the nurse anticipate the provider will prescribe to treat the meningitis?

A patient arrives in the emergency department exhibiting symptoms of a cerebrovascular accident (CVA). Which diagnostic evaluations would the nurse anticipate before treatment is initiated?

A nurse is preparing to administer 40 mg of furosemide intravenously. The available furosemide is 10 mg/1 mL. How many mL should the nurse administer per dose? Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.

The nurse is precepting a new nurse who is caring for a patient with a history of Huntington’s disease. The new nurse is preparing to feed the patient lunch. What action by the new nurse would cause the precepting nurse to intervene?

In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?