Nokea
A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching? (Select all that apply.)
- A. Acyclovir (Zovirax)
- B. Carbamazepine (Tegretol)
- C. Famciclovir (Famvir)
- D. Prednisone (Deltasone)
- E. Valacyclovir (Valtrex)
Correct Answer: A,C,D,E
Rationale: Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.
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A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Assessing the client's gag reflex
- B. Cutting foods up into small bites
- C. Monitoring potassium levels
- D. Weighing the client daily
- E. Thickening liquids to prevent aspiration
Correct Answer: B,D
Rationale: Cutting food up into smaller bites makes it easier for the client to chew and swallow. The UAP can weigh the client daily to monitor nutritional status. Assessing the gag reflex and monitoring potassium levels are tasks that require nursing judgment and cannot be delegated to UAP. Thickening liquids is typically a nursing or dietary intervention, not a UAP task.
A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)
- A. Do not eat a full meal for 45 minutes after taking the drug
- B. Seek immediate care if you develop trouble swallowing
- C. Take this drug on an empty stomach for best absorption
- D. The dose may change frequently depending on symptoms
- E. Your urine may turn a reddish-orange color while on this drug
Correct Answer: A,B,D
Rationale: Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not necessary, and the client's urine will not turn reddish-orange.
A client had a nerve laceration repair to the forearm and is being discharged in a cast. What statement by the client indicates a poor understanding of discharge instructions relating to cast care?
- A. I can scratch with a coat hanger
- B. I should feel my fingers for warmth
- C. I will keep the cast clean and dry
- D. I will return to have the cast removed
Correct Answer: A
Rationale: Nothing should be placed under the cast to use for scratching, as this can cause skin damage or infection. The other statements show a good understanding of cast care instructions.
The nurse caring for a client with Guillain-Barr?© syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.)
- A. Ask occupational therapy to help the client with activities of daily living
- B. Communicate with physical therapy for a consult
- C. Provide the client with information on support groups
- D. Refer the client to a medical social worker or chaplain
- E. Work with speech therapy to design a high-protein diet
Correct Answer: A,B,E
Rationale: Improving mobility and strength involves the collaborative assistance of occupational therapy, physical therapy, and speech therapy for nutritional support. While support groups, social work, or chaplain referrals may be needed, they do not directly help with mobility.
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth. What action by the nurse is best?
- A. Ask the client to explain his feelings related to this disorder
- B. Ask how dental hygiene is related to overall health
- C. Tell the client that he will become malnourished in time
- D. Inform the client about dental care options
Correct Answer: A
Rationale: Clients with trigeminal neuralgia are often afraid of causing pain, so they may limit eating, talking, dental hygiene, and socializing. The nurse first assesses the client for feelings related to having the disorder to determine if a psychosocial link is involved. The other options may be needed depending on the outcome of the initial assessment.