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 D

Explanation

A. Clear and equal breath sounds bilaterally

Explanation: Clear and equal breath sounds bilaterally indicate normal lung sounds, suggesting proper air exchange in both lungs. This is a normal finding and does not require immediate reporting.

B. Oxygen saturation of 98% on room air

Explanation: An oxygen saturation level of 98% on room air indicates adequate oxygenation of the blood. This is a normal and healthy oxygen saturation level and does not require immediate reporting.

C. Cough producing clear, thin sputum

Explanation: A cough producing clear, thin sputum is indicative of a non-infected or non-inflammatory condition in the respiratory system. Clear and thin sputum is often normal, especially in the absence of other symptoms. It does not require immediate reporting unless the client has other concerning symptoms.

D. Visible use of accessory muscles during inhalation

Explanation: Visible use of accessory muscles, such as neck or intercostal muscles, during inhalation suggests that the client is working hard to breathe. This could indicate respiratory distress, potentially due to conditions like asthma, COPD (Chronic Obstructive Pulmonary Disease), or other severe lung problems. It's a concerning sign and should be reported to the healthcare practitioner promptly for further evaluation and intervention.

A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose. B. The client involuntary blinks in the presence of bright light directed over the pupils during the eye exam. C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils. D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.

Correct Answer is A

Explanation

A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose.

This statement is correct. Visual accommodation is the process by which the eye's lens changes shape to focus on objects at varying distances. When an object moves closer to the eyes, the pupils constrict to adjust and focus on the near object, preventing double vision.

B. The client involuntarily blinks in the presence of bright light directed over the pupils during the eye exam.

This statement describes the pupillary light reflex, not visual accommodation. The pupillary light reflex is the response of the pupils to light exposure.

C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.

This statement is not accurate. Peripheral vision sharpness is not related to visual accommodation. Visual accommodation mainly involves adjusting focus for objects at varying distances.

D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.

This statement is incorrect. Pupils should constrict, not dilate, when focusing on a near object (as in visual accommodation). Dilation occurs in low-light conditions or in response to sympathetic stimulation.

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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?

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