Nokea
The nurse is caring for a client with Bell palsy. Which of the following teaching points is a priority in the management of symptoms for this client?
- A. Avoid stimuli that trigger pain.
- B. Use ophthalmic lubricant and protect the eye.
- C. Encourage semiannual dental exams.
- D. Complete the course of antibiotics as prescribed.
Correct Answer: B
Rationale: The VII cranial nerve supplies muscles to the face. In Bell palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.
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The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client?
- A. Involvement with diversion activities
- B. Enhancement of the immune system
- C. Establishing balanced nutrition
- D. Maintaining a safe environment
Correct Answer: D
Rationale: The primary focus in caring for Parkinson disease is on maintaining a safe environment. Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.
A client adopted at birth recently discovers that Huntington disease is prevalent in the biological family history. The nurse is providing education to the client about the condition. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. In the early stages, people with the disease can participate in most physical activities.
- B. The disease eventually leads to hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements.
- C. Disease-modifying medications for Huntington disease can decrease immune cells and infection protection.
- D. There are specific tests that can be arranged to diagnose whether or not you have the disorder.
- E. Huntington disease is familial; it is not transmitted genetically.
Correct Answer: A,B,C
Rationale: In teaching the client about Huntington disease, the nurse will explain to the client that people with the disease can participate in most physical activities in the early stages, but that the disease eventually causes hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements. The nurse will go on to inform the client that medications for Huntington disease can decrease immune cells and immune protection. There are no specific diagnostic tests for this disorder, and it is transmitted genetically; thus, the nurse will leave out these statements in the teaching.
A client is about to be discharged after undergoing surgery for the treatment of a brain tumor and has a referral in place for medical and radiation oncology. Which component(s) should be included in the discharge teaching for this client? Select all that apply.
- A. Medication regimen
- B. Appointments for chemotherapy or radiotherapy
- C. Adverse effects of chemotherapy or radiation and techniques for managing them
- D. Nutritional support
- E. Electromyography
Correct Answer: A,B,C,D
Rationale: The nurse should include the medication regimen, appointments for chemotherapy and radiotherapy, adverse effects of chemotherapy or radiation and techniques for managing them, and nutritional support as components of the discharge teaching for this client. Electromyography is used in amyotrophic lateral sclerosis (ALS) to validate weakness in the affected muscles and should not be included for the client being discharged after surgery for a brain tumor.
The nurse is caring for a client with head trauma. Which assessment finding(s) would indicate an increasing intracranial pressure (ICP) in this client? Select all that apply.
- A. Stiff neck
- B. Generalized pain
- C. Glasgow Coma Scale of 15
- D. Elevated systolic blood pressure
- E. Brisk pupil response
- F. Wide pulse pressure
Correct Answer: D,F
Rationale: Elevated systolic blood pressure with widening pulse pressure is consistent with Cushing's triad, which occurs late in increasing ICP. Other signs of Cushing's triad include bradycardia and irregular breathing. Stiff neck is not a symptom associated with ICP. Generalized pain is not significant with ICP unless related to complaint of headache (especially upon awakening). Glasgow Coma Scale of 15 and brisk pupil response are normal findings.
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?
- A. Sleep pattern
- B. Mood and affect
- C. Appetite
- D. Muscle spasms
Correct Answer: D
Rationale: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.