A nurse is caring for a client who recently had a stroke. Which alteration in neurologic function should the nurse expect?
Facial drooping
Frequent diarrhea
Steady gait
Vocal clarity
The Correct Answer is A
A. Facial drooping is a common symptom following a stroke, particularly if it affects areas of the brain responsible for facial movement.
B. Frequent diarrhea is not typically associated with stroke and may be related to other factors.
C. A steady gait is unlikely following a stroke, especially if the stroke has affected motor control or balance.
D. Vocal clarity can be affected after a stroke, but facial drooping is a more immediate and recognizable alteration in neurologic function.
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Correct Answer is C
Explanation
A. This is a dark vertical line that can appear on the abdomen during pregnancy, typically extending from the pubic area to the navel, which is not what is depicted in the image of a Mongolian Spot.
B. A chronic skin condition that results in red, itchy, scaly patches; this does not match the appearance of a Mongolian Spot.
C. This is the correct answer as it refers to a blue-gray pigmentation commonly found on the backs and buttocks of infants, particularly in individuals of Asian or African descent.
D. These are small, white cysts that can appear on the skin, typically on the face, and are not consistent with the description of a Mongolian Spot.
Correct Answer is C
Explanation
A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.
B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.
C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.
D. Grimacing is an objective observation by the nurse, not a subjective report from the client.