A patient was diagnosed with Bell's Palsy.
Which intervention should the nurse include in the care of this patient?
Provision of a fan to cool the face.
Precautions against aspiration.
Protection of the eye on the paralyzed side.
Medication for pain relief.
The Correct Answer is C
Choice A rationale
Bell's Palsy causes unilateral facial muscle weakness or paralysis, leading to difficulty closing the eye and impaired tear production on the affected side. A fan could further dry the compromised eye, potentially causing irritation and corneal damage.
Choice B rationale
Bell's Palsy primarily affects facial nerve (Cranial Nerve VII) function, which controls facial expressions, taste, and lacrimation. While some patients may experience mild dysphagia, aspiration precautions are not typically the primary or most common concern, as the vagus nerve (Cranial Nerve X) controls swallowing.
Choice C rationale
Due to paralysis of the orbicularis oculi muscle, patients with Bell's Palsy cannot adequately close their affected eye. This can lead to corneal dryness, irritation, and potential ulceration. Therefore, protecting the eye with artificial tears, eye patches, or ointments is crucial to prevent corneal damage.
Choice D rationale
Bell's Palsy is characterized by sudden facial paralysis and may cause discomfort or pain in some individuals, but it is not typically known for severe, debilitating pain requiring primary focus on pain relief. The primary interventions revolve around eye protection and managing the facial paralysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Motor weakness is a common symptom in both hemorrhagic and thrombotic strokes because both types of stroke disrupt blood flow to brain regions responsible for motor control. Ischemic damage or compression from hemorrhage within motor cortex or descending motor tracts can lead to similar presentations of contralateral hemiparesis or hemiplegia, making it non-specific for differentiation.
Choice B rationale
Sensory changes, such as paresthesia or numbness, can occur in both hemorrhagic and thrombotic strokes. This is due to damage to sensory pathways in the brain, including the thalamus or somatosensory cortex. The specific location and extent of brain injury determine the precise sensory deficits, which can be similar regardless of stroke etiology.
Choice C rationale
A sudden onset of severe headache is a hallmark symptom distinguishing hemorrhagic stroke. This intense headache, often described as "the worst headache of my life," results from the rapid increase in intracranial pressure and meningeal irritation caused by blood extravasation into the subarachnoid space or brain parenchyma, unlike thrombotic strokes.
Choice D rationale
A history of hypertension is a significant risk factor for both hemorrhagic and thrombotic strokes. Chronic uncontrolled hypertension damages arterial walls, predisposing them to rupture in hemorrhagic stroke or promoting atherosclerosis and thrombus formation in ischemic stroke. Therefore, its presence does not specifically differentiate between the two types.
Correct Answer is B
Explanation
Choice A rationale
Pork, particularly cuts like bacon or sausage, often contains high levels of saturated fat and sodium, which are detrimental to cardiovascular health and contradict the principles of the DASH diet. The DASH diet emphasizes lean protein sources to reduce fat intake and promote heart health.
Choice B rationale
Turkey, especially lean cuts like turkey breast without skin, is an excellent protein source for a DASH diet. It is low in saturated fat and cholesterol, providing high-quality protein necessary for tissue repair and maintenance without contributing to elevated blood pressure or dyslipidemia.
Choice C rationale
Beef, particularly fattier cuts, can be high in saturated fat and cholesterol, which should be limited in a DASH diet designed to lower blood pressure and improve cardiovascular health. While lean beef can be consumed in moderation, other protein sources are often preferred for their lower fat content.
Choice D rationale
Lamb, especially some cuts, can be high in saturated fat and cholesterol, similar to fattier cuts of beef. While it offers protein, its higher saturated fat content makes it a less optimal choice compared to leaner options for individuals adhering to a DASH diet focused on reducing cardiovascular risk factors.
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