The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

Fatigue.

Pain when eating.

Nausea.

Altered taste sensation.

Answer and Explanation

The Correct Answer is B

A.   While fatigue can contribute to decreased appetite, it is not as directly linked to the specific condition of trigeminal neuralgia.
B.   Trigeminal neuralgia is characterized by severe, sharp facial pain, often triggered by chewing, talking, or even a gentle breeze. This pain would significantly deter a person from eating, leading to imbalanced nutrition.
C.   Nausea is not a typical symptom of trigeminal neuralgia and would not be the primary cause of imbalanced nutrition in this case.
D.   While altered taste can affect food enjoyment, it is less likely to completely deter someone from eating compared to the intense pain associated with trigeminal neuralgia.

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Correct Answer is B

Explanation

A. While oxygen saturation is important, it's not the priority in this situation. The client's symptoms strongly suggest hypoglycemia.
B. The client's symptoms of diaphoresis, rapid heartbeat, and shakiness are classic signs of hypoglycemia. Therefore, the first action should be to confirm this diagnosis by checking the blood glucose level.
C. Administering glucose before confirming hypoglycemia can be dangerous. If the client is hyperglycemic, giving them sugar will worsen their condition.
D. Providing food without confirming hypoglycemia is not appropriate.

A. Encourage active range of motion exercises. B. Assist with ambulation in the hallway. C. Provide a bedside commode for toileting. D. Teach to sleep in a side lying position.

Correct Answer is C

Explanation

A. Range of motion exercises are important for overall mobility and prevention of complications from immobility. However, they can increase cardiac workload, especially if performed actively and without supervision.
B. Ambulation, or walking in the hallway, increases cardiac workload and can exacerbate symptoms in a client with unstable angina. This activity should be minimized or restricted until the client's condition stabilizes. The focus should be on reducing activities that put additional stress on the heart.

C. Using a bedside commode helps reduce the need for the client to walk to the bathroom, which can be physically demanding and increase cardiac workload. By minimizing the effort required for toileting, the client can avoid unnecessary physical strain.
D. Sleeping in a side-lying position is not directly related to reducing cardiac workload. The client's position during sleep generally does not have as significant an impact on cardiac workload as other interventions.

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The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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