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A patient is diagnosed with Bell's palsy and has signs of unilateral facial paralysis and is unable to close his right eye. What eye care is required?
- A. The patient will need to instill artificial teardrops and use an eye patch.
- B. None, since the symptoms will disappear in a few weeks.
- C. Increase fluid intake to prevent dryness of the eye.
- D. Wear sunglasses.
Correct Answer: A
Rationale: Protecting the exposed eye is crucial in Bell's palsy to prevent corneal damage.
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Several cultural groups avoid direct eye contact and consider it disrespectful or aggressive. Which cultural group may not return a direct gaze?
- A. Arab
- B. Asian
- C. Hispanic
- D. Native American
Correct Answer: B
Rationale: In many Asian cultures, avoiding direct eye contact signifies respect, particularly toward authority figures or elders.
How should the nurse respond when asked his or her opinion about treatment decisions by the client or their family?
- A. Provide evidence-based recommendations while respecting autonomy.
- B. Defer all decisions to the physician.
- C. Share personal opinions openly.
- D. Avoid giving any opinion.
Correct Answer: A
Rationale: Providing evidence-based recommendations while respecting the client's autonomy ensures informed decision-making and maintains professionalism.
What is the primary symptom of Bell’s palsy?
- A. Facial drooping
- B. Hearing loss
- C. Eye pain
- D. Tinnitus
Correct Answer: A
Rationale: Bell’s palsy is characterized by sudden onset of unilateral facial drooping due to cranial nerve VII dysfunction.
Priority Decision: A patient in the last stages of life is experiencing shortness of breath and air hunger. Based on practice guidelines, what is the most appropriate action by the nurse?
- A. Administer oxygen.
- B. Administer bronchodilators.
- C. Administer antianxiety agents.
- D. Use any methods that make the patient more comfortable.
Correct Answer: D
Rationale: Comfort measures tailored to the individual patient’s needs are prioritized in palliative care, ensuring the patient feels supported and comfortable.
For each of the nursing diagnoses listed, identify at least two normal expected physiologic changes related to aging that could be etiologic factors of the diagnosis.
- A. Imbalanced nutrition: less than body requirements
- B. Activity intolerance
- C. Risk for injury
- D. Urge urinary incontinence
Correct Answer: A
Rationale: Aging-related changes include decreased appetite, reduced muscle mass, impaired balance, and increased bladder sensitivity—all contributing to various nursing diagnoses.