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The nurse is developing a plan of care for a patient newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease?
- A. Tinnitus
- B. Facial paralysis
- C. Pain at the base of the tongue
- D. Diplopia
Correct Answer: B
Rationale: Bell's palsy causes facial paralysis due to cranial nerve VII dysfunction. Tinnitus, tongue pain, and diplopia are not characteristic of this condition.
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The nurse is developing a plan of care for a patient with Guillain-Barr?© syndrome. Which of the following interventions should the nurse prioritize for this patient?
- A. Using the incentive spirometer as prescribed
- B. Maintaining the patient on bed rest
- C. Providing aids to compensate for loss of vision
- D. Assessing frequently for loss of cognitive function
Correct Answer: A
Rationale: Incentive spirometry maximizes respiratory function, critical in Guillain-Barr?© due to potential respiratory muscle weakness. Bed rest increases complications, and vision or cognition are not typically affected.
The nurse is caring for a patient with multiple sclerosis (MS). The patient tells the nurse the hardest thing to deal with is the fatigue. When teaching the patient how to reduce fatigue, what action should the nurse suggest?
- A. Taking a hot bath at least once daily
- B. Resting in an air-conditioned room whenever possible
- C. Increasing the dose of muscle relaxants
- D. Avoiding naps during the day
Correct Answer: B
Rationale: Resting in a cool, air-conditioned environment reduces body temperature, which can alleviate MS-related fatigue. Hot baths exacerbate fatigue, muscle relaxants may worsen it, and naps are beneficial.
A patient presents at the clinic complaining of pain and weakness in her hands. On assessment, the nurse notes diminished reflexes in the upper extremities bilaterally and bilateral loss of sensation. The nurse knows that these findings are indicative of what?
- A. Guillain-Barr?© syndrome
- B. Myasthenia gravis
- C. Trigeminal neuralgia
- D. Peripheral nerve disorder
Correct Answer: D
Rationale: Pain, weakness, diminished reflexes, and sensory loss in the extremities indicate a peripheral nerve disorder. Guillain-Barr?© involves ascending paralysis, myasthenia gravis affects voluntary muscles, and trigeminal neuralgia causes facial pain.
A patient diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions?
- A. Applying a protective eye shield at night
- B. Chewing on the affected side to prevent unilateral neglect
- C. Avoiding the use of analgesics whenever possible
- D. Avoiding brushing the teeth
Correct Answer: A
Rationale: Bell's palsy can impair eye closure, risking corneal damage, so a protective eye shield at night is essential. Chewing on the affected side is difficult, analgesics may be needed, and oral hygiene should continue.
A patient with suspected Creutzfeldt-Jakob disease (CJD) is being admitted to the unit. The nurse would expect what diagnostic test to be ordered for this patient?
- A. Cerebral angiography
- B. ABG analysis
- C. CT
- D. EEG
Correct Answer: D
Rationale: EEG shows a characteristic pattern in CJD, aiding diagnosis. CT may rule out other conditions, but angiography and ABGs are not diagnostic for CJD.