A patient was diagnosed with Bell's palsy. Which intervention should the nurse include in the care of this patient?

Protection of the eye on paralyzed side

Provision of a fan to cool the face

Medication for pain relief

Precautions against aspiration

Answer and Explanation

The Correct Answer is A

A. Protection of the eye on paralyzed side. Bell's palsy causes unilateral facial paralysis due to inflammation of cranial nerve VII (facial nerve), affecting eyelid closure. Clients are at risk for corneal drying and injury due to incomplete blinking and lagophthalmos (inability to close the eye completely). Nursing interventions include applying artificial tears, taping the eyelid shut at night, and using an eye patch or protective glasses to prevent corneal abrasions and ulcers.
B. Provision of a fan to cool the face. Clients with Bell's palsy often experience facial nerve sensitivity. Exposure to cold air or wind can trigger pain and muscle spasms, making a fan inappropriate. Instead, keeping the face warm and avoiding drafts can help reduce discomfort.
C. Medication for pain relief. Pain is not a primary symptom of Bell's palsy, though some clients may experience mild facial discomfort or headaches. While analgesics (e.g., NSAIDs) may be used for mild pain, the main focus of treatment is corticosteroids to reduce inflammation and protect facial nerve function.
D. Precautions against aspiration. Bell’s palsy does not affect swallowing function because it involves cranial nerve VII (facial nerve), not cranial nerves IX and X (which control swallowing). Clients may have drooling due to facial muscle weakness, but aspiration precautions are not typically necessary unless another neurological issue is present.

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Correct Answer is B

Explanation

A. "It can increase their blood pressure." Most sedative medications, such as benzodiazepines and antipsychotics, typically cause sedation and hypotension, rather than increasing blood pressure. While some medications may have cardiovascular side effects, hypertension is not the primary concern when prescribing sedatives for clients with dementia.
B. "It can increase their risk for falls." Sedating medications, including antipsychotics and benzodiazepines, cause dizziness, drowsiness, and impaired coordination, significantly increasing the risk of falls in older adults. Dementia already affects balance, judgment, and gait, making fall prevention a top priority in this population.
C. "It can increase their risk for infection." While some medications can suppress immune function, sedatives and antipsychotics do not directly increase infection risk. The primary concern with their use in older adults with dementia is fall risk, confusion, and worsening cognitive decline.
D. "It increases their risk of experiencing a stroke." While certain antipsychotics (e.g., risperidone, olanzapine) carry a black box warning for increased stroke risk in dementia patients, this risk is not the primary reason for avoiding sedatives. Falls and associated complications, such as fractures and head injuries, are a more immediate concern in this population.

A. Assess for the presence of chest pain B. Inspect the skin for rashes or discoloration C. Ask the patient about any increase in libido. D. Inquire about urinary tract problems

Correct Answer is D

Explanation

A: "Assess for the presence of chest pain." While chest pain is an important symptom to evaluate in many patients, it is not specifically related to multiple sclerosis (MS). MS primarily affects the central nervous system and may not directly cause chest pain, making this assessment less relevant in the context of suspected MS.
B: "Inspect the skin for rashes or discoloration." Although skin changes can occur in various conditions, they are not characteristic of MS. MS primarily involves neurological symptoms, so inspecting the skin may not provide significant information regarding the patient's condition.
C: "Ask the patient about any increase in libido." Changes in libido are not typically associated with MS. Patients may experience various symptoms, including fatigue and mobility issues, but libido changes are not a primary concern or common symptom linked to the disease.
D: "Inquire about urinary tract problems." This is a relevant assessment for a patient with possible MS. Urinary dysfunction is common in individuals with MS due to neurological damage affecting bladder control. Patients may experience urgency, frequency, or incontinence, making it essential to assess urinary tract issues during the health history and physical examination. Addressing these concerns can help guide appropriate management strategies.

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A patient was diagnosed with Bell's palsy. Which intervention should the nurse include in the care of this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has dementia. The client's family member asks why the provider will not prescribe a medication to calm the client down. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should

Correct Answer is D

Explanation

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