A nurse working in the cardiac icu is caring for client with suspected left sided heart failure. For which clinical manifestation should the nurse assess for?

A) Stop taking ordered corticosteroid once symptoms resolve:
Corticosteroids, such as prednisone, are commonly prescribed to reduce inflammation in Bell’s Palsy, especially during the acute phase. However, it is important to complete the full course of corticosteroids as prescribed, even if symptoms improve. Abruptly stopping corticosteroids can lead to rebound inflammation and potentially worsen the condition.

B) Apply warm compresses to the affected area several times a day:
Warm compresses can help to reduce pain and inflammation in the affected side of the face. Applying them several times a day can also help improve circulation and ease the discomfort associated with Bell's Palsy. This is a recommended self-care strategy that can help provide relief and improve overall comfort for the client during recovery.

C) Cover the affected eye with an eye protective shield or patch at night:
Bell's Palsy can lead to paralysis of the facial muscles, which may make it difficult for the client to fully close the eyelid on the affected side, leaving the eye vulnerable to dryness and injury. Covering the eye with a protective shield or patch at night helps prevent corneal damage and protects the eye from exposure during sleep. This is an essential part of eye care for a client with Bell’s Palsy to prevent complications.

D) Chew food only on the affected side:
There is no medical recommendation to limit chewing to the unaffected side. In fact, clients should be encouraged to use both sides of their mouth for chewing to prevent muscle atrophy and maintain function. There is no evidence to support that chewing food only on the affected side provides any benefit.

E) Place artificial tears or lubricant to help decrease dryness in the eyes:
Since Bell's Palsy can impair the ability to close the eyelid fully, this can lead to dryness and potential corneal damage on the affected side. Artificial tears or lubricating eye drops should be used regularly to moisturize the eye and prevent complications such as corneal ulcers or abrasions.

A) Continue to monitor as this is a normal response to the medication: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not normal responses to the edrophonium test and suggest a cholinergic crisis rather than a simple reaction to the medication. A cholinergic crisis occurs when there is overmedication with cholinergic drugs, leading to excessive stimulation of the parasympathetic nervous system. While mild effects like slight nausea or dizziness can occur, cramping, diaphoresis, and increased oral secretions indicate toxicity, requiring immediate intervention.

B) Administration of atropine: The symptoms the patient is exhibiting—cramping, diaphoresis, and increased oral secretions—are indicative of cholinergic toxicity. Edrophonium, a cholinesterase inhibitor, is used in the Tensilon test to diagnose myasthenia gravis by temporarily improving muscle strength. However, in some cases, the patient may experience a cholinergic crisis from an overdose of the medication, resulting in excess acetylcholine at synapses, which overstimulates the parasympathetic nervous system. Atropine, an anticholinergic agent, blocks the effects of acetylcholine and is used to reverse these symptoms by reducing the excessive parasympathetic activity (e.g., reducing secretions and improving heart rate).

C) Place the patient in the Trendelenburg position: The Trendelenburg position (head down, feet up) is often used in cases of shock to help increase venous return to the heart. However, it is not appropriate for a cholinergic crisis. The patient’s symptoms are not due to hypotension or shock but are related to an overdose of edrophonium causing parasympathetic overstimulation.

D) Administer diphenhydramine (Benadryl) for the allergic reaction: The symptoms the patient is experiencing (cramping, diaphoresis, increased oral secretions) are not related to an allergic reaction. Diphenhydramine (Benadryl) is an antihistamine used for allergic reactions, such as urticaria or anaphylaxis, but it does not treat cholinergic toxicity.