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.
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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 is teaching the parent of a 7-year-old client with celiac disease. Which statement by the parent would require follow-up?
- A. My child can consume small amounts of barley
- B. My child is allowed to eat rice, corn, and potatoes
- C. My child needs to be on a gluten-free diet for life
- D. My child should avoid eating processed foods
Correct Answer: A
Rationale: Barley contains gluten, which is harmful in celiac disease, indicating a need for further teaching. Rice, corn, potatoes, lifelong gluten-free diet, and avoiding processed foods are correct.
A transfusion is ordered for a hospitalized client. The charge nurse asks the LPN to start the transfusion. What should the LPN do?
- A. Start the transfusion as ordered
- B. Be sure that dextrose is hanging and then hang the blood
- C. Tell the RN that LPNs are not allowed to hang blood
- D. Hang the blood only if an IV line is already established
Correct Answer: C
Rationale: LPNs typically cannot initiate blood transfusions due to scope of practice limitations, as it requires specialized monitoring, so the LPN should inform the RN.
A diabetic client asks the nurse why she should use a diaphragm as a method of contraception instead of birth control pills. The best explanation for the use of a diaphragm is:
- A. A diaphragm will best prevent pregnancy because oral contraceptives are rendered ineffective by increased glucose levels.
- B. A diaphragm is a noninvasive method of contraception that will not alter the blood glucose levels.
- C. A diaphragm will provide intrauterine contraception by preventing implantation of the embryo.
- D. A diaphragm is a noninvasive method of contraception that prevents the egg from being released from the ovary.
Correct Answer: B
Rationale: A diaphragm does not affect blood glucose, unlike oral contraceptives, which can alter glycemic control. Oral contraceptives are not ineffective due to glucose levels, diaphragms do not prevent implantation or ovulation, and they are not intrauterine.
The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking Eskalith (lithium carbonate). Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. An apple
- D. A milkshake
Correct Answer: C
Rationale: Lithium carbonate can cause sodium depletion, and high-sodium snacks like potato chips should be avoided to prevent toxicity. Diet cola lacks nutritional value and may contain caffeine, which can exacerbate mania. An apple is a healthy, low-sodium snack that supports hydration and nutrition. A milkshake may be high in sugar or fat, which is less ideal.