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Which should be the nurse's first intervention with the client diagnosed with Bell's palsy?
- A. Explain that this disorder will resolve within a month.
- B. Tell the client to apply heat to the involved side of the face.
- C. Encourage the client to eat a soft diet.
- D. Teach the client to protect the affected eye from injury.
Correct Answer: D
Rationale: Bell’s palsy impairs eye closure, risking corneal damage. Teaching eye protection (D) is the priority. Resolution timeline (A), heat (B), and diet (C) are secondary.
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The client is brought to the emergency department by the police for public disorderliness. The client reports feeling no pain and is unconcerned that the police have arrested him. The nurse notes the client has epistaxis and nasal congestion. Which substance should the nurse suspect the client has abused?
- A. Marijuana.
- B. Heroin.
- C. Ecstasy.
- D. Cocaine.
Correct Answer: D
Rationale: Cocaine (D) causes epistaxis, nasal congestion, and euphoria with pain insensitivity. Marijuana (A), heroin (B), and ecstasy (C) do not typically cause these nasal symptoms.
Which nursing action is priority for a client with a stroke experiencing unilateral neglect?
- A. Place objects on the unaffected side.
- B. Encourage bilateral arm exercises.
- C. Provide a mirror for self-awareness.
- D. Teach the client to scan the environment.
Correct Answer: D
Rationale: Teaching the client to scan the environment compensates for unilateral neglect, promoting safety and awareness.
The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his room. Which intervention should the nurse implement first?
- A. Insist that the client go to the dining room for meals.
- B. Notify the family of the change in behavior.
- C. Determine if the client wants another roommate.
- D. Complete a Geriatric Depression Scale.
Correct Answer: D
Rationale: Social withdrawal may indicate depression. Completing a Geriatric Depression Scale (D) is the first step to assess this possibility. Forcing dining (A), notifying family (B), or changing roommates (C) are premature without assessment.
Which client statement indicates understanding of trigeminal neuralgia management?
- A. I'll apply heat to my face for pain relief.'
- B. I'll avoid chewing on the affected side.'
- C. I'll use a hard toothbrush for oral hygiene.'
- D. I'll wash my face with cold water.'
Correct Answer: B
Rationale: Avoiding chewing on the affected side reduces pain triggers in trigeminal neuralgia.
The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan?
- A. Monitor the client’s respirations frequently.
- B. Refer to a dermatologist for treatment of maculopapular rash.
- C. Treat hypothermia by using ice packs under the client’s arms.
- D. Teach the client to report any swollen lymph glands.
Correct Answer: A
Rationale: Severe West Nile virus can cause neurological and respiratory complications, so monitoring respirations (A) is critical. Rash (B) is self-limiting, hypothermia (C) is not typical, and lymph glands (D) are not a primary concern.