Nokea
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Bell's palsy is characterized by muscle distortion due to facial nerve paralysis, leading to asymmetry in facial expressions (A). Pain behind the ear may occur due to inflammation or compression of the facial nerve (B). Impaired taste can result from altered function of the chorda tympani nerve, affecting taste sensation on the anterior two-thirds of the tongue (E). Choices C, D, F, G are incorrect as hearing loss is not a typical feature of Bell's palsy (C), facial twitching is more characteristic of conditions like hemifacial spasm (D), and there are no specific findings associated with F and G in Bell's palsy.
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A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Turn and position each client every 2 hr.
- B. Identify the clients at greatest risk for development of pressure ulcers.
- C. Use a barrier cream when performing perineal care.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: B
Rationale: The correct answer is B: Identify the clients at greatest risk for development of pressure ulcers. This is the priority because it allows for targeted interventions to be implemented for those most vulnerable, maximizing resources and preventing potential harm. Turning and positioning clients, using barrier creams, and ensuring adequate nutrition are all important aspects of pressure ulcer prevention, but they should be tailored based on individual risk assessment. Supervising nutritional intake is crucial, but not the immediate priority in preventing pressure ulcers. Identifying high-risk clients allows for proactive measures to be taken, making it the most critical step in meeting the National Safety Goal.
A nurse is reviewing the plan of care for a client who has a respiratory infection. The nurse should plan to have the client lie on his stomach with pillows elevating his chest and stomach to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: C
Rationale: Prone positioning with elevation allows mucus drainage from posterior lung segments.
A charge nurse is assisting a newly-licensed nurse to insert an indwelling urinary catheter for a male client. Which of the following actions requires the charge nurse to intervene?
- A. Lubricates the first 2.5 to 5 cm (1 to 2 in) of the catheter tubing
- B. Lubricates the first 15 to 17.5 cm (6 to 7 in) of the catheter
- C. Secures the tubing to the client's upper thigh
- D. Secures the tubing to the client's lower abdomen.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The correct action for inserting an indwelling urinary catheter in a male client is to lubricate the first 15 to 17.5 cm (6 to 7 in) of the catheter, not just the first 2.5 to 5 cm (1 to 2 in). This is crucial to ensure smooth insertion and prevent trauma to the urethra. Therefore, the charge nurse should intervene and guide the newly-licensed nurse to lubricate the appropriate length of the catheter tubing.
Summary of Incorrect Choices:
B: Lubricating the first 15 to 17.5 cm (6 to 7 in) of the catheter is the correct action, not an intervention.
C: Securing the tubing to the client's upper thigh is a proper step to prevent pulling on the catheter, not requiring intervention.
D: Securing the tubing to the client's lower abdomen is also a standard practice to prevent dislod
A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect?
- A. Ability to perform oral hygiene
- B. Ability to bathe himself
- C. Ability to identify how often he should schedule his car for an oil change
- D. Ability to balance his bank account
- E. Ability to dress himself
Correct Answer: A,B,E
Rationale: Assessing ADLs includes evaluating self-care abilities like hygiene, bathing, and dressing.
A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?
- A. They'll protect your legs and heels from skin breakdown.
- B. They'll help keep you warm immediately after your surgery.
- C. They'll improve your circulation to keep blood from pooling in your legs.
- D. They'll make it easier for you to do leg exercises after your surgery.
Correct Answer: C
Rationale: Correct Answer: C. They'll improve your circulation to keep blood from pooling in your legs.
Rationale:
1. Antiembolism stockings apply gentle pressure to the legs, promoting blood flow.
2. Improved circulation helps prevent blood clots by reducing the risk of venous stasis.
3. By preventing blood pooling, the stockings decrease the chances of deep vein thrombosis.
Incorrect Choices:
A. Skin breakdown prevention is not the primary purpose of antiembolism stockings.
B. Keeping warm is not the main function of these stockings.
D. While leg exercises are important post-surgery, it is not the main reason for using antiembolism stockings.