A patient presents to the Emergency Department (ED) reporting right facial weakness. The nurse understands that a patient suffering from Bell's Palsy will exhibit which assessment findings related to the cranial nerve involvement?

painful areas on the affected side following 3 branches of the nerve

decreased visual acuity when tested with Snellen Chart

unilateral upper and lower facial weaknesses including forehead

facial dropping, with arm and leg weakness on the affected side

Answer and Explanation

The Correct Answer is C

A) Painful areas on the affected side following 3 branches of the nerve:
This is not typically a feature of Bell's Palsy. Bell's Palsy is primarily a motor dysfunction of the facial nerve (cranial nerve VII), leading to facial weakness. The pain associated with Bell's Palsy, if present, is usually mild and localized to the jaw, behind the ear, or along the jawline rather than along all three branches of the trigeminal nerve (cranial nerve V), which controls sensation in the face. Therefore, this choice is not consistent with the typical presentation of Bell's Palsy.

B) Decreased visual acuity when tested with Snellen Chart:
Decreased visual acuity is not a primary feature of Bell's Palsy. This condition specifically affects facial nerve function, which controls the muscles of facial expression, including those responsible for closing the eyes tightly. However, Bell's Palsy does not typically result in visual changes such as decreased visual acuity or problems with vision itself. Decreased vision would be more indicative of an issue with the optic nerve (cranial nerve II) or other eye-related conditions.

C) Unilateral upper and lower facial weakness including forehead:
This is the hallmark sign of Bell's Palsy. The facial nerve (cranial nerve VII) controls the muscles of the face, and when it becomes affected by Bell's Palsy, both the upper and lower parts of the face on one side can be weak or paralyzed. Importantly, Bell's Palsy causes inability to wrinkle the forehead, which distinguishes it from stroke, where the forehead is typically spared because the upper part of the facial muscles receives bilateral input from the brain. Thus, both upper and lower facial weakness, including inability to raise the eyebrow (forehead), is characteristic of Bell's Palsy.

D) Facial dropping, with arm and leg weakness on the affected side:
Facial drooping is a common symptom of Bell's Palsy, but arm and leg weakness is not associated with it. Arm and leg weakness on the same side would be more suggestive of a stroke affecting the cerebrovascular system, rather than a peripheral nerve issue like Bell's Palsy. Bell's Palsy is confined to facial nerve dysfunction and does not cause weakness in the limbs.

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Correct Answer is A

Explanation

A) Insertion of a cardioverter-defibrillator:
Hypertrophic cardiomyopathy (HCM) is a condition characterized by abnormal thickening of the heart muscle, particularly the septum, which can lead to obstruction of blood flow and contribute to the development of arrhythmias. The most concerning arrhythmias in HCM include ventricular tachycardia and ventricular fibrillation, both of which can lead to sudden cardiac arrest. A cardioverter-defibrillator (ICD) is a device that monitors the heart's rhythm and can deliver a shock to restore normal rhythm in the event of a life-threatening arrhythmia.

B) A medication regimen that includes nitrates:
Nitrates are vasodilators commonly used in the treatment of conditions like angina and heart failure. However, nitrates are generally avoided in patients with hypertrophic cardiomyopathy because they can exacerbate the condition by decreasing preload and increasing the outflow tract obstruction due to the thickened heart muscle.

C) Immediate cardiac transplantation:
Cardiac transplantation is a treatment for end-stage heart failure, typically in patients who have not responded to medical or surgical treatments. While hypertrophic cardiomyopathy can lead to heart failure, it is not the first line treatment for dysrhythmias or complications from the disease.

D) Insertion of a drug-eluting stent:
Drug-eluting stents are used to prevent restenosis (narrowing) of coronary arteries after percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). However, hypertrophic cardiomyopathy is not caused by coronary artery disease.

A. Assess lung sounds and respiratory rate at least every 2 hours B. Assess and document pain level once every shift C. Maintain sequential compression device (SCD's) while in bed D. Elevate the head of the bed ten degrees

Correct Answer is A

Explanation

A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.

B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.

C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.

D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.

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A patient presents to the Emergency Department (ED) reporting right facial weakness. The nurse understands that a patient suffering from Bell's Palsy will exhibit which assessment findings related to the cranial nerve involvement?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for client who is diagnosed with hypertrophic cardiomyopathy. Which medical Intervention should the nurse anticipate for this client for the complications of dysrhythmias?

Correct Answer is A

Explanation

The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

Correct Answer is A

Explanation

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