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) Prepare for a STAT computed tomography (CT) scan:
A severe headache in a client with a suspected stroke could be indicative of increased intracranial pressure (ICP), a hemorrhagic stroke, or another serious complication like cerebral edema. The priority intervention is to perform a CT scan to determine whether the stroke is ischemic (caused by a blockage) or hemorrhagic (caused by bleeding). This is crucial because the treatment approach for these two types of strokes differs significantly. For example, hemorrhagic strokes require immediate management to control bleeding and reduce ICP, whereas ischemic strokes may be treated with thrombolytics or other interventions. Therefore, preparing for a CT scan is the most urgent action to accurately diagnose the type of stroke and guide treatment decisions.

B) Obtain a 12-lead electrocardiogram (ECG):
While an ECG may be useful in assessing the cardiac rhythm and identifying potential arrhythmias (which can contribute to stroke risk), it is not the priority intervention in a patient with a suspected stroke and severe headache. The primary concern is to identify the type of stroke (ischemic or hemorrhagic), and a CT scan is the most direct way to do this. A 12-lead ECG can be obtained later if cardiac issues are suspected after stroke diagnosis.

C) Start an intravenous infusion of D5W at 100 mL/hr:
Starting an IV infusion of D5W (5% dextrose in water) is not an appropriate priority for a patient with a severe headache and suspected stroke. In fact, administering dextrose solutions may worsen the patient's condition in the case of a hemorrhagic stroke, as it could exacerbate cerebral edema or increase intracranial pressure. Fluid management in stroke patients should be approached cautiously, and IV fluids should be tailored to the patient's specific needs. The focus should be on imaging to determine the type of stroke before initiating interventions like IV fluids.

D) Administer a nonnarcotic analgesic:
While pain relief is important, administering a nonnarcotic analgesic (such as acetaminophen or ibuprofen) is not the priority in this situation. The patient's severe headache could be a sign of a serious complication like increased ICP or hemorrhagic stroke, which requires immediate diagnostic workup, not just pain management. Administering pain medication without understanding the underlying cause of the headache could mask symptoms and delay critical treatment.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with a stroke complains of a severe headache. Which intervention would be the nursing priority?

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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