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

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
Speaking slowly and clearly using yes/no questions one at a time can help facilitate communication with a client diagnosed with aphasia.
Choice B rationale

Asking a family member if they know what the client wants may not always be effective, as the client may have difficulty expressing their needs even to family members.
Choice C rationale
Repeating the same question multiple times may not be effective and could potentially frustrate the client.
Choice D rationale
Putting a cell phone in their right hand to text their questions assumes that the client has the ability to text, which may not be the case for all clients diagnosed with aphasia.

A. Support the right arm with a sling or pillow to prevent shoulder dislocation. B. Anticipate the client will exhibit some degree of expressive or receptive aphasia. C. Place the wheelchair on the client’s left side when transferring him into a wheelchair. D. Provide close supervision because of the client’s impulsiveness and poor judgment.

Correct Answer is D

Explanation

Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale

Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client that has been diagnosed with aphasia. How can the nurse communicate effectively with the client?

Correct Answer is A

Explanation

The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

Correct Answer is D

Explanation

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