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: "Give the ordered PRN acetaminophen (Tylenol)." Acetaminophen is generally not effective for treating cluster headaches, as these headaches are characterized by severe pain that does not respond well to over-the-counter pain medications. Therefore, administering acetaminophen would not address the immediate need for relief.
B: "Start the prescribed PRN O2 at 6 L/min." Administering oxygen at 6 L/min is a recognized and effective treatment for cluster headaches. Inhaling oxygen can help alleviate the headache by causing vasoconstriction of the dilated cerebral vessels and improving oxygen supply to the brain. This intervention should be prioritized to provide the patient with prompt relief from the acute headache.
C: "Put a moist hot pack on the patient's neck." While applying heat can provide comfort for some types of headaches, it is not effective for cluster headaches. These headaches are often exacerbated by heat and require different management strategies.
D: "Notify the patient's health care provider immediately." Although it may be necessary to inform the healthcare provider about the patient's condition, immediate relief for the cluster headache should take precedence. The nurse can initiate the oxygen therapy first to address the patient's acute pain before considering further interventions or notifications.

A. Provide a nonskid mat to alleviate plate movement. B. Remind the client to look for food on the left side of the tray. C. Encourage the use of the wide grip utensils. D. Encourage the client to use his right hand when feeding himself.

Correct Answer is B

Explanation

A: "Provide a non-skid mat to alleviate plate movement." Using a non-skid mat can help prevent the plate from moving, but it does not address the specific issue of homonymous hemianopsia, which affects the client's visual field and ability to see food on one side.
B: "Remind the client to look for food on the left side of the tray." This strategy directly addresses the challenge posed by homonymous hemianopsia, which results in the loss of vision in half of the visual field. Reminding the client to scan the left side of the tray helps ensure that they can locate and eat their food more effectively.
C: "Encourage the use of the wide grip utensils." While using wide grip utensils may assist with grip and dexterity, it does not specifically address the visual field deficit caused by homonymous hemianopsia. This option does not improve the client’s ability to see the food they need to eat.
D: "Encourage the client to use his right hand when feeding himself." Using the right hand may not be beneficial for the client. If the client has right-sided stroke effects, using the right hand could be difficult due to weakness or hemiparesis. Promoting the use of the unaffected side is usually more effective in fostering independence in eating.

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

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