Nokea
The nurse is collecting data from a client with Bell’s palsy. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. Inability to smile symmetrically
- B. Frequent blinking of the affected eye
- C. Shock-like pain in the lips and gums
- D. Loss of forehead and brow movements
- E. Decreased lacrimation on the affected side
Correct Answer: A,D,E
Rationale: Bell’s palsy causes unilateral facial weakness, leading to asymmetrical smiling, loss of forehead/brow movement, and reduced lacrimation. Frequent blinking is unlikely due to impaired muscle control, and shock-like pain is typical of trigeminal neuralgia.
You may also like to solve these questions
The nurse is teaching a client about newly prescribed amlodipine. Which adverse effect would be most important for the nurse to include?
- A. Depression
- B. Dizziness
- C. Dry cough
- D. Erectile dysfunction
Correct Answer: B
Rationale: Dizziness, due to amlodipine’s vasodilatory effect, is a common and critical side effect, risking falls, especially in the elderly. Depression, cough, and erectile dysfunction are less common or associated with other drugs.
The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:
- A. Infection with the tubercle bacillus
- B. Exposure to the tubercle bacillus
- C. Questionable exposure to the tubercle bacillus
- D. No exposure to the tubercle bacillus
Correct Answer: B
Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.
An 85-year-old woman is hospitalized with a fractured hip. She complains to the LPN/LVN that she feels something is wrong and her chest hurts. The nurse notes the client has tachypnea. What should the nurse do immediately?
- A. Administer oxygen
- B. Take vital signs
- C. Elevate the head of the bed
- D. Give aspirin
Correct Answer: B
Rationale: Chest pain and tachypnea suggest a possible pulmonary embolism post-hip fracture; taking vital signs provides critical data for immediate assessment.
The nurse in the pediatric unit is collecting data from several newly admitted clients. Which finding should the nurse follow up for possible abuse and mandatory reporting?
- A. A 2-month-old who rolled off the changing table and is now lethargic
- B. A 3-month-old with flat bluish discoloration on the buttock that the mother says has been present since birth
- C. A 3-year-old with forehead bruises that the mother says resulted from running into a table
- D. A 4-year-old who pulled boiling water off the stove and has splatter burns on the arms
Correct Answer: A
Rationale: A 2-month-old cannot roll, and lethargy after a fall suggests possible non-accidental head trauma, requiring abuse investigation. Bluish buttock marks may be Mongolian spots (benign), and splatter burns are consistent with an accident.
A client with cancer of the stomach has a gastric resection. The nurse should tell the client that following surgery:
- A. He can eat any type food he wants to eat.
- B. Proteins and vitamins will assist with healing.
- C. He will only be able to have high-calorie liquids.
- D. Increasing his fat intake will help promote healing.
Correct Answer: B
Rationale: Proteins and vitamins support tissue repair post-gastrectomy. Any food may cause dumping syndrome. High-calorie liquids are too restrictive. High fat delays gastric emptying.