A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke?
a. Slow onset of fac...
A client presents in the emergency room with right-sided facial
asymmetry. The nurse asks the client to perform a series of movements
that require use of the facial muscles. What symptoms suggest that the
client has most likely experience a Bell's palsy rather than a stroke?
a. Slow onset of facial drooping associated with headache
b. Inability to close the affected eye, raise brow, or smile
c. A flat nasolabial fold on the right resulting in facial asymmetry.
d. Drooling is present on right side of the mouth, but not on the left. -
Precise Answer ✔✔Inability to close the affected eye, raise brow, or
smile
Rationale: Because the motor function controlling eye closure, brow
movement and smiling are all carried on the 7th cranial (facial) nerve,
the combination of symptoms directly relating to an impairment of all
branches of the facial nerve indicate that Bell's palsy has occurred.
The nurse is teaching a client how to perform colostomy irrigations.
When observing the client's return demonstration, which action indicated
that the client understood the teaching?
a. Turns to left the side to instill the irrigating solution into the stoma
b. Keeps the irrigating container less than 18 inches above the stoma
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,c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation
d. Inserts irrigating catheter deeper into stoma when cramping occurs -
Precise Answer ✔✔Keeps the irrigating container less than 18 inches
above the stoma
Rationale: Keeping the irrigating container less than 18 inches above the
stoma permits the solution to flow slowly with little excessive peristalsis
does not cause immediate release of stool.
The nurse should teach the client to observe which precaution while
taking dronedarone?
a. Stay out of direct sunlight
b. Avoid grapefruits and its juice
c. Reduce the use of herbal supplements
d. Minimize sodium intake. - Precise Answer ✔✔b. Avoid grapefruits
and its juice
Rationale: Grapefruit increase the effect of dronedarone thereby
increasing the possibility of serious side effects. A does not cause a
serious effect. C may potentiate lethal arrhythmias and should be
avoided. D does not directly affect those taking dronedarone.
A client who sustained a head injury following an automobile collision
is admitted to the hospital. The nurse include the client's risk for
developing increased intracranial pressure (ICP) in the plan of care.
Which signs indicate to the nurse that ICP has increased?
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, a. Increased Glasgow coma scale score.
b. Nuchal rigidity and papilledema.
c. Confusion and papilledema
d. Periorbital ecchymosis. - Precise Answer ✔✔Confusion and
papilledema
Rationale: papilledema is always an indicator of increased ICP, and
confusion is usually the first sign of increased ICP. Other options do not
necessarily reflect increased ICP.
The nurse is caring for a client receiving continuous IV fluids through a
single lumen central venous catheter (CVC). Based on the CVC care
bundle, which action should be completed daily to reduce the risk for
infection?
a. Remind staff to follow protective environment precautions
b. Gently flush the catheter lumen with sterile saline solution
c. Cleanse the site and change the transparent dressing.
d. Confirm the necessity for continued use of the CVC. - Precise Answer
✔✔Confirm the necessity for continued use of the CVC
Rationale: Increase the length of use increase the risk for infection. The
CVC care bundle includes the review of the need for continued use of
the CVC. Effective hand hygiene and standard precautions should be
maintained but protective environment precautions are not needed. B is
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