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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 findings for a client with Bell's palsy are muscle distortion, pain behind the ear, and impaired taste. Muscle distortion occurs due to facial nerve paralysis, leading to drooping or weakness on one side of the face. Pain behind the ear can result from inflammation of the facial nerve. Impaired taste can occur due to dysfunction of the taste buds innervated by the facial nerve. Hearing loss (C) is not typically associated with Bell's palsy. Facial twitching (D) may occur in other conditions like hemifacial spasm but not a defining feature of Bell's palsy.
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A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is D, respiratory alkalosis. Hyperventilation causes excessive loss of carbon dioxide, leading to respiratory alkalosis. This is evidenced by lightheadedness, paresthesias, blurred vision, and confusion due to decreased carbon dioxide levels in the blood. Metabolic acidosis (A) is characterized by low pH and bicarbonate levels, not seen in this scenario. Metabolic alkalosis (B) is due to excess bicarbonate, which is not present in hyperventilation. Respiratory acidosis (C) is caused by retention of carbon dioxide, opposite of what is seen in hyperventilation.
A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, “Go away! No one can help me.†Which of the following responses should the nurse make?
- A. Everything will be ok.
- B. I will come back later and we can talk.
- C. Why are you crying?
- D. Do you think crying will help?
Correct Answer: B
Rationale: The correct answer is B: "I will come back later and we can talk." This response shows empathy, respect for the client's autonomy, and a willingness to provide support without being intrusive. By offering to come back later, the nurse acknowledges the client's feelings and demonstrates a willingness to engage in a supportive conversation when the client is ready.
Choice A is incorrect because it dismisses the client's feelings without offering meaningful support. Choice C may come off as confrontational and put the client on the defensive. Choice D is dismissive and lacks empathy, potentially making the client feel unsupported. Overall, choice B is the best response as it respects the client's feelings and allows for a supportive conversation at a later time.
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 provider prescribes isometric exercises for a client who has a knee injury. The nurse should instruct the client to expect which of the following results from completing these exercises regularly?
- A. Increased muscle strength and tone to reduce muscle wasting
- B. Muscle hypertrophy to compensate for decreased joint strength
- C. Promotion of venous stasis to reduce the risk of embolus formation
- D. Reduction in bone density loss to prevent osteoporosis
Correct Answer: A
Rationale: The correct answer is A: Increased muscle strength and tone to reduce muscle wasting. Isometric exercises involve muscle contraction without joint movement, which helps improve muscle strength and tone. This is crucial in preventing muscle wasting commonly seen in clients with knee injuries. Muscle hypertrophy (B) is more associated with resistance training, not isometric exercises. Promotion of venous stasis (C) is incorrect as isometric exercises actually promote circulation and reduce the risk of blood clots. Reduction in bone density loss (D) is not directly related to isometric exercises.
A nurse is instructing a client about postural drainage. The nurse should have the client lie on his stomach with his head lower than his feet to mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: D
Rationale: Prone Trendelenburg position aids in secretion clearance from posterior lung segments.