Nokea
The nurse makes a home care visit to a client diagnosed with Bell's palsy. Which statement by the client indicates a need for further teaching?
- A. I wear an eye patch at night.
- B. I am staying on a liquid diet.
- C. I wear dark glasses when I go out.
- D. I have been gently massaging my face.
Correct Answer: B
Rationale: Bell's palsy is caused by a lower motor neuron lesion of the seventh cranial nerve that may result from infection, trauma, hemorrhage, meningitis, or tumor. It is not necessary for a client diagnosed with Bell's palsy to stay on a liquid diet. The client should be encouraged to chew on the unaffected side. Wearing an eye patch at night, dark glasses for daytime outings, and gently massaging the face identify accurate statements related to the management of Bell's palsy.
You may also like to solve these questions
The community health is conducting a health screening clinic. The nurse interprets that which client participating in the screening is the highest priority client to provide instruction to lower the risk of developing respiratory disease?
- A. A smoker who works in an acute care hospital
- B. A person who works with lawn care pesticides
- C. A person who does woodworking as a hobby for 8 years
- D. A smoker who has cracked asbestos lining on the basement pipes
Correct Answer: D
Rationale: The client who smokes and has exposure to cracked asbestos lining is at the highest risk for respiratory disease due to the combined effects of smoking and asbestos, both potent lung irritants. Smoking alone or other exposures (pesticides, woodworking) pose risks, but the dual exposure in option D is the most severe.
The nurse is reviewing the assessment data of a client. Which finding is most important for the client to modify to lessen the risk for coronary artery disease (CAD)?
- A. Elevated triglyceride levels
- B. Elevated serum lipase levels
- C. Elevated serum testosterone level
- D. Elevated low-density lipoprotein (LDL) levels
Correct Answer: D
Rationale: Elevated LDL levels are most directly linked to CAD, as they contribute to atherosclerosis. Triglycerides are a risk factor but less predictive, lipase is unrelated to CAD, and low testosterone, not high, may influence CAD risk.
The nurse provides home care instructions to a client who has been diagnosed with recurrent trichomoniasis. The nurse determines the need for follow-up teaching if the client indicates she should take which action?
- A. Avoid sexual intercourse.
- B. Perform good perineal hygiene.
- C. Use the metronidazole as prescribed.
- D. Discontinue treatment during menstruation.
Correct Answer: D
Rationale: Treatment for a recurrent vaginal trichomoniasis infection continues through the menstrual period because the vagina is more alkaline during menses, and a flare-up is more likely to occur. While the infection remains active, the client should refrain from sexual intercourse or instruct her partner to wear a condom. To help break the chain of infection, the nurse directs the client to perform perineal hygiene after each voiding and each bowel movement. Metronidazole must be taken as prescribed.
The nurse in an ambulatory clinic administers a tuberculin skin test to a client on a Monday. When should the nurse tell the client to return to the clinic to have the results read?
- A. Thursday or Friday
- B. The following Monday
- C. Tuesday or Wednesday
- D. Wednesday or Thursday
Correct Answer: D
Rationale: The tuberculin skin test for tuberculosis is read in 48 to 72 hours; therefore, the client should return to the clinic on Wednesday or Thursday.
The mother of a child with celiac disease asks the nurse how long a special diet is necessary. The nurse provides which instruction to the mother to promote dietary compliance?
- A. A gluten-free diet will need to be followed for life.
- B. A lactose-free diet will need to be followed temporarily.
- C. Added dietary sodium will help prevent episodes of celiac crisis.
- D. Supplemental vitamins, iron, and folate will prevent complications.
Correct Answer: A
Rationale: Celiac disease is characterized by intolerance to gluten, the protein component of wheat, barley, rye, and oats. The main nursing consideration with celiac disease is helping the child adhere to dietary management. The treatment of celiac disease consists primarily of dietary management with a gluten-free diet. Options 2 and 4 are true statements, but they do not answer the question that the client is asking. Children with untreated celiac disease may have lactose intolerance, which usually improves with gluten withdrawal. Additional sodium does not prevent celiac crisis. Low levels of potassium, calcium, and magnesium are most likely to be present. Nutritional deficiencies resulting from malabsorption are treated with appropriate supplements.