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 B

Explanation

A. Oriented to person, place, and year: Meningitis often causes alterations in mental status, including confusion and disorientation. Therefore, the client may not be fully oriented to person, place, and time.

B. Severe headache: Headache is a hallmark symptom of meningitis and is often described as severe and persistent. It may be accompanied by other symptoms such as photophobia (sensitivity to light) and phonophobia (sensitivity to sound).

C. Bradycardia: Bradycardia is not typically associated with meningitis. In fact, tachycardia (elevated heart rate) may be present due to fever and systemic inflammation.

D. Blurred vision: While meningitis can lead to increased intracranial pressure, which may manifest as papilledema (swelling of the optic disc), blurred vision is not a common presenting symptom of meningitis. Visual changes are more commonly associated with conditions affecting the optic nerve or retina.

A. Catheterize the patient every 3 to 4 hours. B. Administer medications to reduce bladder spasm. C. Assist the patient to ambulate 4 times daily. D. Stabilize the neck when repositioning the patient.

Correct Answer is B

Explanation

A. Catheterize the patient every 3 to 4 hours: Catheterization may be necessary for urinary retention, which is common in cauda equina syndrome, but it should not be done routinely every 3 to 4 hours. Indwelling catheters increase the risk of urinary tract infections and should be avoided unless necessary.

B. Administer medications to reduce bladder spasm: Bladder spasm is a common complication of cauda equina syndrome and can lead to urinary retention. Medications such as anticholinergics or alpha-adrenergic blockers may be prescribed to reduce bladder spasm and facilitate urine elimination.

C. Assist the patient to ambulate 4 times daily: Ambulation may not be appropriate for a patient with cauda equina syndrome, especially if they have significant motor or sensory deficits. Ambulation should be assessed on an individual basis and may require assistance or adaptive devices.

D. Stabilize the neck when repositioning the patient: Cauda equina syndrome affects the lower spinal cord and does not typically involve the cervical spine. Stabilizing the neck is important in patients with cervical spine injuries but is not directly related to cauda equina syndrome.

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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

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Which action should the nurse include in the plan of care for a patient who has cauda equina syndrome related to spinal cord injury?

Correct Answer is B

Explanation

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)