The nurse is conducting an assessment on a patient suspected of having a stroke. Which assessment finding is most indicative of a stroke?
Facial droop
Dysrhythmias
Periorbital edema
Projectile vomiting
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Herpes simplex virus encephalitis is a severe condition that requires immediate treatment. The most common medication used for this condition is acyclovir, which is administered intravenously. Acyclovir works by inhibiting the replication of the virus, thereby reducing the severity and duration of the infection.
Choice B rationale
Cyclosporine is an immunosuppressive medication that is often used to prevent organ rejection after transplantation. It is not typically used in the treatment of viral infections such as herpes simplex virus encephalitis.
Choice C rationale
Without specific information about “Medication C”, it’s difficult to provide a rationale.
However, it’s important to note that the treatment of herpes simplex virus encephalitis typically involves antiviral medications, with acyclovir being the most commonly used.
Choice D rationale
Similar to Choice C, without specific information about “Medication D”, providing a rationale is challenging. As mentioned, the standard treatment for herpes simplex virus encephalitis is acyclovir.
Correct Answer is C
Explanation
Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.
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