Nokea
The nurse is teaching a patient who is at risk for Bell's palsy because of previous herpes simplex infection. Which of the following information should the nurse include?
- A. Call the doctor if pain or herpes lesions occur near the ear.
- B. Treatment of herpes with antiviral agents prevents Bell's palsy.
- C. You may be able to prevent Bell's palsy by doing facial exercises regularly.
- D. Medications to treat Bell's palsy work only if started before paralysis onset.
Correct Answer: A
Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.
You may also like to solve these questions
After a young adult patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the partner is performing many of the activities that the patient had been managing during rehabilitation. Which of the following actions by the nurse is most appropriate at this time?
- A. Tell the partner that the patient can perform activities independently.
- B. Remind the patient about the importance of independence in daily activities.
- C. Develop a plan to increase the patient's independence in consultation with the patient and the partner.
- D. Recognize that it is important for the partner to be involved in the patient's care and support the partner's participation.
Correct Answer: C
Rationale: The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviours of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.
The nurse is caring for a patient with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?
- A. Respect the patient's desire and arrange for privacy at mealtimes.
- B. Teach the patient to chew food on the unaffected side of the mouth.
- C. Offer the patient liquid nutritional supplements at frequent intervals.
- D. Discuss the patient's concerns with visitors who arrive at mealtimes.
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
The nurse is admitting a patient with a spinal cord injury. Which of the following collaborative and nursing actions should the nurse do immediately? (Select all that apply.)
- A. Stabilize spine with sand bags
- B. Nasogastric (NG) tube feeding
- C. Ensure patency of airway
- D. Avoidance of cool room temperature
- E. Insert Foley catheter
Correct Answer: A,C,E
Rationale: Immediate care for a patient with a spinal cord injury is to ensure a patent airway, stabilize the spine with a hard collar or sand bags, and insert a Foley catheter. Avoidance of a cool room temperature is not part of immediate care. A tube feeding would not be initiated in the immediate postinjury care period.
The nurse is caring for a patient who sustained a spinal cord injury a week ago and becomes angry, telling the nurse 'I want to be transferred to a hospital where the nurses know what they are doing!' Which of the following actions by the nurse is best?
- A. Ask for the patient's input into the plan for care.
- B. Clarify that abusive behaviour will not be tolerated.
- C. Reassure the patient about the competence of the nursing staff.
- D. Continue to perform care without responding to the patient's comments.
Correct Answer: A
Rationale: The patient is demonstrating behaviours consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.
The nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury. Which of the following goals should the nurse include for this patient?
- A. Transfer independently to a wheelchair.
- B. Drive a car with powered hand controls.
- C. Turn and reposition independently when in bed.
- D. Push a manual wheelchair on flat, smooth surfaces.
Correct Answer: D
Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.