The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

"You may be able to prevent Bell's palsy by doing facial exercises regularly."

"Medications to treat Bell's palsy work only if started before paralysis onset."

"Call the doctor if you experience pain or develop herpes lesions near the ear."

"Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy."

Answer and Explanation

The Correct Answer is C

A. "You may be able to prevent Bell's palsy by doing facial exercises regularly." Regular facial exercises have not been proven to prevent Bell's palsy. In fact, excessive facial exercises could potentially exacerbate symptoms in some cases.

B. "Medications to treat Bell's palsy work only if started before paralysis onset." While early treatment with antiviral medications may be beneficial in some cases, it is not accurate to say that medications only work if started before paralysis onset. Treatment can still be effective even after the onset of symptoms, although it may not be as effective as when started early.

C. "Call the doctor if you experience pain or develop herpes lesions near the ear." This is important information because Bell's palsy has been associated with reactivation of the herpes simplex virus. Pain or the development of herpes lesions near the ear could indicate impending or active Bell's palsy, and prompt medical evaluation is necessary.

D. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." While antiviral medications can reduce the risk of herpes simplex virus reactivation, there is no guarantee that prophylactic treatment will prevent Bell's palsy. However, prompt treatment of herpes outbreaks may help reduce the risk.

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Correct Answer is []

Explanation

The client is most likely experiencing meningitis based on the following clinical manifestations:

Symptoms: The client presents with a 2-day history of lethargy, nausea, vomiting, anorexia, headache, general muscle aches, diarrhea, abdominal pain, sore throat, sensitivity to light, and intermittent nystagmus. These symptoms are consistent with the classic signs of meningitis, including headache, nausea, vomiting, photophobia, and altered mental status.
Physical Examination Findings: The physical examination reveals a fever (temperature of 38.9°C or 102°F), elevated heart rate (118/min), and signs of meningeal irritation such as neck stiffness (not directly mentioned but implied by headache and sensitivity to light). Additionally, a pinpoint, red, macular rash on the upper chest may indicate petechiae, which can be seen in meningococcal meningitis.

Given the suspicion of meningitis, the nurse should take the following actions:

Implement seizure precautions: Meningitis can lead to increased intracranial pressure and neurological complications, including seizures. Implementing seizure precautions involves ensuring the client's safety by padding the side rails of the bed, keeping the bed in a low position, and providing close observation.
Dim the lights in the client’s room: The client reports sensitivity to light, which is a common symptom of meningitis due to meningeal irritation. Dimming the lights can help reduce discomfort and photophobia in the client.

Parameters to Monitor:

Neurologic status: Monitoring the client's neurologic status is crucial for assessing the progression of meningitis and detecting any neurological deterioration, such as changes in level of consciousness, motor deficits, or signs of increased intracranial pressure.
Temperature: Monitoring the client's temperature is essential to assess for fever spikes or trends, which can indicate the severity of the infection and response to treatment.

Persistent or worsening fever may suggest inadequate treatment or complications such as abscess formation.

A. Cardiac monitoring for bradycardia B. Administration of low-molecular-weight heparin C. Assessment of respiratory rate and effort D. Application of pneumatic compression devices to legs

Correct Answer is C

Explanation

A. Cardiac monitoring for bradycardia: While cardiac changes can occur with spinal cord injury, respiratory complications are more common and pose a greater immediate threat to the patient's well-being. Therefore, assessing respiratory status takes priority over cardiac monitoring in this situation.

B. Administration of low-molecular-weight heparin: Venous thromboembolism prophylaxis is important for patients with spinal cord injury, but it is not the highest priority within the first 16 hours of admission. Respiratory assessment is more critical for immediate patient safety.

C. Assessment of respiratory rate and effort: Respiratory complications, such as impaired breathing or respiratory failure, are common in patients with spinal cord injury, particularly at the C5 level, which affects the diaphragm and intercostal muscles. Early detection of respiratory distress is crucial for timely intervention to prevent respiratory compromise.

D. Application of pneumatic compression devices to legs: Pneumatic compression devices are used for preventing venous thromboembolism, but they do not address the immediate priority of assessing and managing respiratory status in a patient with spinal cord injury.

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The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

Which action should the nurse recognize as the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury?

Correct Answer is C

Explanation

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