The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding?
Jugular vein distention.
Carotid bruit.
Nuchal rigidity.
Palpable cervical lymph node.
The Correct Answer is B
A. Jugular vein distention:
Jugular vein distention is not typically associated with an increased risk of a stroke. It may be indicative of issues related to cardiac or fluid volume status.
B. Carotid bruit:
This is the correct answer. A carotid bruit, an abnormal sound caused by turbulent blood flow through the carotid artery, may indicate the presence of atherosclerosis and increased risk of stroke. It suggests a narrowing or blockage in the carotid artery, which can potentially lead to emboli and subsequent stroke.
C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck, is associated with conditions such as meningitis but is not a direct risk factor for a stroke.
D. Palpable cervical lymph node:
Palpable cervical lymph nodes may be indicative of infection or inflammation in the head and neck region but are not directly associated with an increased risk of a stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Keep the room at a comfortable temperature:
While maintaining a comfortable room temperature is important for the overall well-being of the client, it is not the most essential intervention during a seizure. The priority during a seizure is to ensure the client's safety, particularly focusing on airway management.
B. Ensure oral suction is available:
This is the most essential intervention. During a seizure, the client may produce excessive saliva, and having oral suction readily available helps prevent airway obstruction and ensures a clear airway. It is crucial for the safety and well-being of the client.
C. Provide frequent mouth care:
Mouth care is important for the overall hygiene of the unconscious client, but it may not be the most immediate priority during a seizure. The focus during a seizure is on preventing complications such as aspiration or airway obstruction.
D. Maintain the client in a semi-Fowler's position:
Positioning is important for the comfort and safety of the unconscious client, but maintaining a semi-Fowler's position may not be the primary concern during an active seizure. The immediate focus is on airway management and preventing injury.

Correct Answer is D
Explanation
A. Eat a diet high in carotene:
While a healthy diet is important for overall well-being, there is no evidence to suggest that a diet high in carotene specifically prevents or treats glaucoma. The focus in glaucoma management is on intraocular pressure control.
B. Wear prescription glasses:
Prescription glasses may be beneficial for addressing refractive errors, but they do not specifically address the management of glaucoma. The client's concern about driving through a tunnel is more likely related to changes in peripheral vision associated with glaucoma.
C. Avoid frequent eye pressure measurements:
This is not the most important instruction. Monitoring intraocular pressure is a crucial aspect of glaucoma management, and the frequency of measurements is determined by the healthcare provider. Regular monitoring helps assess the effectiveness of treatment and disease progression.
D. Maintain the prescribed eye drop regimen:
This is the correct answer. The most important instruction for the client is to adhere to the prescribed eye drop regimen. Medications, often in the form of eye drops, are commonly used to lower intraocular pressure and manage glaucoma. Consistent use of prescribed medications is critical for controlling the condition and preventing further vision loss.

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