A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)

Pain behind the ear

Muscle distortion

Facial twitching

Impaired taste

Hearing loss

Answer and Explanation

Correct Answer : A,B,D

A. Pain behind the ear is a common early symptom of Bell's palsy due to inflammation of the facial nerve.
B. Muscle distortion occurs as the facial muscles on the affected side weaken or become paralyzed, leading to an asymmetrical appearance.
C. Facial twitching is not a common manifestation of Bell's palsy; rather, it involves muscle paralysis or weakness.
D. Impaired taste, especially in the anterior two-thirds of the tongue, can occur due to facial nerve involvement.
E. Hearing loss is not typically associated with Bell's palsy; it usually affects facial motor function, not auditory function.

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Correct Answer is ["C","D","E"]

Explanation

A. Restraints should not be used routinely for clients with seizure disorders, as they can lead to injury and are not recommended for seizure management.
B. A bite stick is not recommended during a seizure because it can cause injury to the client’s teeth and jaw.
C. Keeping an oxygen setup at the bedside is essential to provide supplemental oxygen if the client experiences difficulty breathing during or after a seizure.
D. Elevating the side rails when the client is in bed helps prevent falls and injuries during a seizure, providing a safer environment.
E. A suction setup at the bedside is important to clear secretions and prevent aspiration during a seizure, especially if the client has impaired swallowing or is at risk for aspiration.

A. Measure the client's apical pulse rate for 30 seconds before administration. B. Withhold the medication if the client's heart rate is above 100/min. C. Instruct the client to eat foods that are low in potassium. D. Monitor the client for nausea, vomiting, and yellow vision.

Correct Answer is D

Explanation

A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.
B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.
C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.
D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.

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A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan?

Correct Answer is ["C","D","E"]

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Correct Answer is D

Explanation

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