A nurse is assessing a client who has been recently diagnosed with Bell's palsy. Which of the following findings should the nurse expect? [Select all that apply.]

Unilateral facial drooping

Unilateral arm weakness

Alopecia

Difficulty swallowing

Inability to close the affected eye

Answer and Explanation

Correct Answer : A

A) Unilateral facial drooping:
Unilateral facial drooping is the hallmark sign of Bell's palsy, a condition that results from inflammation of the facial nerve (cranial nerve VII). This inflammation causes muscle weakness or paralysis on one side of the face, leading to drooping of the mouth, eyelid, and other facial features on the affected side. The facial drooping may worsen with smiling, closing the eyes, or other facial expressions, making this a key finding in Bell’s palsy.

B) Unilateral arm weakness:
Unilateral arm weakness is not typically associated with Bell's palsy, which specifically affects the facial muscles due to nerve damage. While weakness can occur in other parts of the body due to neurological conditions, it is not a characteristic symptom of Bell’s palsy, which is primarily a cranial nerve issue. Therefore, arm weakness would prompt consideration of other potential neurological causes.

C) Alopecia:
Alopecia, or hair loss, is not a common symptom of Bell's palsy. Although it can be seen in many different conditions, it is not typically linked with Bell's palsy, which is a disorder of the facial nerve. Bell’s palsy affects facial muscles, leading to symptoms like drooping or inability to close the eye, but it does not directly cause hair loss.

D) Difficulty swallowing:
Difficulty swallowing (dysphagia) can occur in Bell's palsy, especially if the facial nerve affects the ability to control the muscles involved in swallowing. This may lead to difficulty with chewing, swallowing, or speaking clearly. While not always severe, dysphagia is a potential complication due to the involvement of the facial nerve, which controls facial muscles essential for these functions.

E) Inability to close the affected eye:
The inability to close the affected eye is a common symptom of Bell's palsy due to paralysis of the orbicularis oculi muscle, which is controlled by the facial nerve. This can lead to dryness or irritation of the eye and a risk for corneal damage if the eye is not properly closed or protected. This inability to close the eye is one of the hallmark features of Bell's palsy.

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Correct Answer is B

Explanation

A) Limit fluid intake:
There is no evidence to suggest that limiting fluid intake is necessary or beneficial for clients with multiple sclerosis (MS). In fact, staying well-hydrated is often encouraged, especially for individuals with bladder dysfunction or those at risk for urinary retention or constipation, which are common symptoms of MS. Restricting fluid intake could exacerbate these issues and is not a priority in MS management.

B) Utilize assistive devices as needed:
The most important aspect of teaching for a client recently diagnosed with multiple sclerosis is to encourage the use of assistive devices as needed. MS often causes mobility issues, weakness, and coordination difficulties due to damage to the nervous system. Using devices like canes, walkers, or wheelchairs can significantly improve independence and safety, helping the client maintain mobility and prevent falls

C) Schedule eye examinations every other year:
Eye problems, such as optic neuritis or diplopia (double vision), are common in MS, but the frequency of eye exams depends on the individual’s symptoms. Regular eye exams are important, but every other year is generally not frequent enough. Most MS patients are advised to have annual eye exams or as recommended by their ophthalmologist, especially if they experience any changes in vision.

D) Double up on any missed scheduled medications:
Doubling up on missed medications is not recommended, as it can lead to overdose or increase the risk of side effects. It is important to follow the prescribed medication regimen and use strategies to help the client remember their medications, such as setting reminders or using a medication organizer.

A. "Take one tablet every 15 during an acute attack." B. "Take this medication after each meal and at bedtime." C. "Take one tablet at the first indication of chest pain." D. ‘’Take this medication with 8 ounces of water."

Correct Answer is C

Explanation

A) "Take one tablet every 15 minutes during an acute attack."
This is incorrect because the correct instruction is to take one tablet every 5 minutes for up to 3 doses during an acute angina attack, not every 15 minutes. If the chest pain persists after three doses, the client should seek immediate medical attention. Taking a tablet every 15 minutes would delay intervention and could be dangerous in an acute situation.

B) "Take this medication after each meal and at bedtime."
This is not the correct instruction for nitroglycerin use during an angina attack. Nitroglycerin tablets are typically used on an as-needed basis to relieve acute chest pain (angina). They are not intended for routine use after meals or at bedtime. If taken routinely for prevention of angina, the dosing regimen would be different, usually in the form of extended-release formulations.

C) "Take one tablet at the first indication of chest pain."
Nitroglycerin tablets are used to relieve chest pain (angina) by relaxing coronary arteries and improving blood flow to the heart. The client should take one tablet at the first sign of chest pain. If the pain does not resolve within 5 minutes, the client should take a second tablet, and a third if needed, with a total of 3 doses being the maximum before seeking emergency care. This allows for quick relief during an acute angina attack.

D) "Take this medication with 8 ounces of water."
Nitroglycerin tablets should not be taken with water. They are typically absorbed sublingually (under the tongue) and should not be swallowed or taken with water. Taking them with water could delay the absorption process and reduce their effectiveness.

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A nurse is assessing a client who has been recently diagnosed with Bell's palsy. Which of the following findings should the nurse expect? [Select all that apply.]

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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