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) Unilateral upper extremity weakness:
Guillain-Barré Syndrome (GBS) typically presents with bilateral weakness, not unilateral. The weakness in GBS typically begins symmetrically in the lower extremities and ascends upward toward the upper body, including the arms, face, and respiratory muscles. Therefore, unilateral weakness is not characteristic of GBS, and its presence should prompt further investigation into other possible causes.

B) Bilateral ascending weakness:
One of the hallmark signs of Guillain-Barré Syndrome is ascending weakness, which means that the weakness usually starts in the lower extremities (legs) and progresses upwards to the upper extremities, face, and potentially the respiratory muscles. This bilateral ascending paralysis is a classic feature of GBS and occurs due to the immune system attacking the myelin sheath of peripheral nerves. The nurse should be vigilant for signs of progressive weakness, as GBS can quickly lead to respiratory failure and requires prompt intervention.

C) Mask-like facial expressions:
Mask-like facial expressions are more commonly associated with Parkinson's disease, not Guillain-Barré Syndrome. Parkinson’s disease is characterized by a reduction in facial expressiveness due to the loss of dopaminergic neurons, leading to a fixed, unblinking, or "masked" appearance. While facial involvement can occur in GBS as the weakness ascends, it is not typically described as a "mask-like" expression.

D) Pill rolling actions made by the client's fingers:
Pill-rolling is a characteristic tremor often associated with Parkinson's disease and involves the repetitive motion of the fingers, as if rolling a pill. It is a resting tremor seen in Parkinson's disease and not in Guillain-Barré Syndrome. GBS primarily presents as weakness and loss of motor function, rather than tremors or other involuntary movements.

A. Normal saline 1 liter to client who is dehydrated B. Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain C. Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain D. Lorazepam 2 mg IV now for the client who is anxious and restless

Correct Answer is C

Explanation

A) Normal saline 1 liter to client who is dehydrated:
Administering normal saline to a dehydrated client is an important task, as it helps to restore fluid balance and improve circulatory volume. However, while rehydration is critical, it is not an immediate, life-threatening priority compared to other interventions. The nurse should begin this infusion after addressing more urgent needs such as severe chest pain, which could indicate a cardiac emergency.

B) Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain:
Morphine is a potent analgesic, and relieving pain for postoperative patients is essential for comfort and recovery. However, incisional pain, although important to address, is not life-threatening in this scenario. The client with chest pain should be prioritized because chest pain could indicate a myocardial infarction (MI) or other serious cardiac event that requires immediate intervention.

C) Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain:
Crushing chest pain is a classic symptom of acute myocardial infarction (MI), a life-threatening condition that requires immediate intervention. Nitroglycerin is used to relieve chest pain associated with angina or MI by dilating the coronary arteries and improving blood flow to the heart. In this case, chest pain is the most critical symptom, and immediate treatment is necessary to reduce the risk of further cardiac damage or complications.

D) Lorazepam 2 mg IV now for the client who is anxious and restless:
While lorazepam is an effective medication for anxiety and restlessness, it is not the most urgent medication in this case. The client’s anxiety should be addressed, but it does not pose an immediate threat to life. Anxiety can generally be managed after more acute, life-threatening conditions (such as chest pain) are stabilized.

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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.]

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