Nokea
A client has been diagnosed with Bell's palsy. The nurse assesses the client to determine if which signs/symptoms are present?
- A. Eye paralysis and ptosis of the eyelids
- B. Chewing difficulties and one-sided facial droop
- C. Fixed pupil and an elevated eyelid on one side
- D. Twitching of one side of the face and ruddy cheeks
Correct Answer: B
Rationale: Bell's palsy is a one-sided facial paralysis resulting from compression of the facial nerve (CN VII). There is facial droop from paralysis of the facial muscles; increased lacrimation; painful sensations in the eye, face, or behind the ear; and chewing difficulties. The other items listed are not associated with this disorder.
You may also like to solve these questions
A client with a history of tuberculosis is prescribed isoniazid (INH). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Isoniazid can cause hepatotoxicity, requiring regular liver function monitoring.
The physician is calling in an order for ampicillin for a neonate. The nurse should do which of the following? Select all that apply.
- A. Write down the order.
- B. Ask the physician to come to the hospital and write the order on the chart.
- C. Repeat the order to the physician over the telephone.
- D. Ask the physician to confirm that the order is correct.
- E. Ask the nursing supervisor to cosign the telephone order as transcribed by the nurse.
Correct Answer: A,C,D
Rationale: Writing the order, repeating it back, and confirming with the physician ensure accuracy and safety for a telephone order.
A client with a history of heart failure is admitted with dyspnea. The nurse should place the client in which of the following positions?
- A. Fowler's position.
- B. Supine position.
- C. Trendelenburg position.
- D. Left lateral position.
Correct Answer: A
Rationale: Fowler's position (semi-upright) reduces preload and eases breathing in heart failure.
A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed theophylline. The nurse should monitor the client for which of the following adverse effects?
- A. Tachycardia.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Weight loss.
Correct Answer: A
Rationale: Theophylline can cause tachycardia due to its stimulant effects.
The nurse has finished suctioning the tracheostomy of a client. Which parameter should the nurse monitor to determine the effectiveness of the procedure?
- A. Breath sounds
- B. Capillary refill
- C. Respiratory rate
- D. Oxygen saturation level
Correct Answer: A
Rationale: After suctioning a client either with or without an artificial airway, the breath sounds are auscultated to determine the extent to which the airways have been cleared of respiratory secretions. The other assessment items are not as precise as breath sounds for this purpose.