Nokea
A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions?
- A. Report an increase in blurred vision.
- B. Eat soft, warm foods.
- C. Change positions slowly.
- D. Chew food on the affected side.
Correct Answer: B
Rationale: intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain
You may also like to solve these questions
A client who has just indicated a wish to kill herself and asks the nurse not to tell anyone.
The nurse's BEST response should be to
- A. encourage the client not to do anything without thinking it through very carefully.
- B. explain to the client that anything she tells the nurse is kept strictly confidential.
- C. report this to staff members in order to protect the client.
- D. encourage the client to tell the nurse more about what she is feeling.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not answer client's immediate concern or give client accurate information about what the nurse will do (2) does not answer client's immediate concern or give client accurate information about what the nurse will do (3) correct-nurse must let the client know that this information will be shared with the staff so that the client's safety can be preserved (4) does not answer client's immediate concern or give client accurate information about what the nurse will do
In caring for an elderly client with a depressed affect, which of the following nursing actions would be MOST appropriate to help the client to complete activities of daily living?
- A. Medicate the client before the activities begin.
- B. Develop a written schedule of activities, allowing extra time.
- C. Assist the client with grooming activities so it doesn't take as long.
- D. Provide frequent forceful direction to keep the client focused.
Correct Answer: B
Rationale: written schedule with built-in extra time will allow client to understand what is expected and will allow him to participate at a slower pace
The nurse cares for an 8 lb, 8 oz newborn boy. The infant's history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed?
- A. Temperature 97.6°F (36.5°C).
- B. Apical pulse 140 bpm.
- C. Respirations 18.
- D. BP 80/50.
Correct Answer: C
Rationale: magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min
The nurse is performing an ice massage for a client in chronic pain. The nurse is MOST concerned if which of the following is observed?
- A. Redness or inflammation of the tissue.
- B. Mottling or graying of the tissue.
- C. The client states that she feels a burning and tingling sensation in the area.
- D. The client states that she feels a numbness and a cold sensation in the area.
Correct Answer: B
Rationale: Mottling or graying indicates potential frostbite or tissue damage, a serious concern requiring immediate cessation of ice massage. Options A, C, and D are less critical: redness is common, burning/tingling suggests ischemia, and numbness/cold is expected.
The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataractsurgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?
- A. hold the morning dose of NPH and regular insulin and monitor the blood glucose.
- B. give half the morning dose of NPH insulin along with the regular insulin and monitor the blood glucose when the client returns from surgery.
- C. give the full dose of NPH and regular insulin and monitor the blood glucose every 2 to 4 hours.
- D. give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Correct Answer: A
Rationale: usually use sliding scale with regular insulin based on blood glucose readings