The nurse is caring for an older adult client who has recently had a stroke. The nurse assesses that the right side of the client's face is drooping. The nurse might also expect which of the following assessment findings?

Xerostomia

Epistaxis

Dysphagia

Rhinorrhea

Answer and Explanation

The Correct Answer is C

A. Xerostomia: Xerostomia refers to dry mouth, which is caused by reduced saliva production. While it can be a symptom of various conditions, it is not directly associated with facial drooping after a stroke.

B. Epistaxis: Epistaxis is a medical term for a nosebleed. It occurs due to the rupture of small, delicate blood vessels within the nose. While it can happen independently of a stroke, it is not directly related to facial drooping caused by a stroke.

C. Dysphagia: Dysphagia refers to difficulty in swallowing, which can occur after a stroke due to muscle weakness, including the facial muscles. Facial drooping on one side can be indicative of stroke-related muscle weakness and can contribute to difficulties in swallowing.

D. Rhinorrhea: Rhinorrhea is the medical term for a runny nose, where the nasal cavity is filled with a significant amount of mucus. It is usually caused by various factors such as allergies, infections, or irritants. Rhinorrhea is not directly associated with facial drooping after a stroke.

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Correct Answer is A

Explanation

A. Continue with the assessment, looking for any other abnormal findings: This is the correct response. Tonsils in adults can have various appearances, and a granular appearance with deep crypts is within the range of normal. It's essential for the nurse to continue the assessment and observe for other signs or symptoms that might indicate an issue.

B. Refer the patient to a throat specialist: Referring the patient based solely on the appearance of the tonsils, especially if it's a normal variant, might be unnecessary and could cause undue concern for the patient. It's important to assess the patient comprehensively before considering a specialist referral.

C. No response is needed; this appearance is normal for the tonsils: This is the correct explanation. In adults, tonsils often appear granular with deep crypts, which is considered a normal variation. No further action is required regarding the tonsils.

D. Obtain a throat culture on the patient for possible streptococcal (strep) infection: Based on the description provided (involution, granular appearance, and deep crypts), there's no specific indication of a streptococcal infection. Conducting a throat culture should be based on the presence of specific symptoms and signs indicative of a streptococcal infection, such as sore throat, fever, and swollen tonsils with white patches, rather than just the appearance of the tonsils.

A. The location of most breast tumors. B. More prone to Injury and calcifications than other locations in the breast C. The largest quadrant of the breast D. Where most of the suspensory ligaments attach

Correct Answer is A

Explanation

A. The location of most breast tumors: This choice is correct. The upper outer quadrant of the breast is the most common site for breast tumors. This area has a higher concentration of glandular tissue, making it more susceptible to the development of tumors. Therefore, thorough examination of this area is crucial during breast examinations.

B. More prone to Injury and calcifications than other locations in the breast: While injuries can occur in any part of the breast, the statement about calcifications is not accurate. Calcifications in breast tissue can occur in various areas and are not specific to the upper outer quadrant.

C. The largest quadrant of the breast: This statement is not accurate. The breast quadrants are not distinguished by size; they are anatomical divisions used for reference during breast examinations. Each quadrant has its significance for examination purposes, but none is considered the largest.

D. Where most of the suspensory ligaments attach: The suspensory ligaments, also known as Cooper's ligaments, provide structural support to the breast tissue. While they are essential for breast anatomy, they are not concentrated in the upper outer quadrant exclusively. These ligaments are distributed throughout the breast tissue.

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The nurse is caring for an older adult client who has recently had a stroke. The nurse assesses that the right side of the client's face is drooping. The nurse might also expect which of the following assessment findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing the tonsils of an adult client. The nurse notices that the tonsils are involuted, granular in appearance, and has deep crypts. The nurse recognizes that which of the following is the correct response to these findings?

Correct Answer is A

Explanation

The nurse is performing a breast examination on a client. The nurse understands that examining the upper outer quadrant of the breast is especially important because this part is:

Correct Answer is A

Explanation

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