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 A

Explanation

Choice A rationale
For a client with Parkinson’s disease who has difficulty swallowing or chewing due to muscle rigidity, semi-solid food with thick liquids can be easier to swallow and reduce the risk of choking19.
Choice B rationale
Minced foods and fluid restriction may not provide the necessary nutrients and hydration for a client with Parkinson’s disease19.
Choice C rationale
A low-residue diet, which is low in fiber, may not be appropriate for a client with Parkinson’s disease, as constipation is a common symptom of the disease and fiber can help alleviate this19.
Choice D rationale
Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. It is typically reserved for clients who cannot or should not get their nutrition through eating19.

A. Keep a urinary catheter in place for the entire duration of recovery. B. Provide three larger meals rather than frequent small meals. C. Limit the intake of insoluble fiber. D. Teach the patient to perform deep breathing and coughing exercises.

Correct Answer is D

Explanation

Choice D rationale
Teaching the patient to perform deep breathing and coughing exercises is a key intervention to address a potential complication after an ischemic stroke. These exercises can help prevent pneumonia, a common complication after stroke, by promoting lung expansion, improving oxygenation, and facilitating the clearance of secretions.
Choice A rationale
Keeping a urinary catheter in place for the entire duration of recovery is not typically recommended due to the increased risk of urinary tract infections. Catheters should be used sparingly and removed as soon as possible.

Choice B rationale
Providing three larger meals rather than frequent small meals does not specifically address a potential complication after an ischemic stroke. In fact, smaller, more frequent meals may be easier for some stroke patients to manage, particularly if they have difficulty swallowing.
Choice C rationale
Limiting the intake of insoluble fiber does not specifically address a potential complication after an ischemic stroke. A balanced diet with adequate fiber is generally recommended for stroke patients to promote bowel regularity and overall health.

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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

While assessing the breath sounds of a client with Parkinson’s disease, a nurse hears adventitious sounds. How should the client’s nutritional needs be met?

Correct Answer is A

Explanation

The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a potential complication after an ischemic stroke?

Correct Answer is D

Explanation

The nurse is conducting an assessment on a patient suspected of having a stroke. Which assessment finding is most indicative of a stroke?

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