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poopy199 poopy199
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Posts: 359
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6 years ago
The patient is diagnosed with Bell's palsy. The nurse assesses the patient and notices drooping of the patient's right eye and the right side of his mouth.
 
  When the functions of the following nerves are compared, the most likely cause of these symptoms would be a dysfunction of the:
  a. seventh cranial nerve.
  b. trigeminal nerve (CN V).
  c. oculomotor nerve (CN III).
  d. glossopharyngeal nerve (CN IX).

Question 2

The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility.
 
  What does the nurse realize?
  a. This patient should be turned onto his back for meals.
  b. This patient may have to be turned more frequently than every 2 hours.
  c. This patient may be allowed to remain in his favorite position as long as he doesn't complain of discomfort.
  d. Skin breakdown is not an issue for this patient.

Question 3

The patient has been hospitalized for several days and has received multiple intravenous antibiotic medications. This morning, the patient had three episodes of severe, foul-smelling diarrhea . The nurse should institute:
 
  a. contact precautions.
  b. standard precautions only.
  c. airborne precautions.
  d. droplet precautions.

Question 4

The patient was found in an alley on a cold winter night and is admitted with hypothermia from environmental exposure. She is elderly and is having difficulty breathing. Her breath sounds are diminished, and the tip of her nose is cyanotic.
 
  The nurse wants to assess the oxygen level in the patient's blood. She decides to use the pulse oximeter. The best way to apply this to this patient would be with a(n):
  a. finger probe.
  b. earlobe sensor.
  c. forehead sensor.
  d. toe sensor.
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Replies
wrote...
6 years ago
The answer to question 1

A
Assess cranial nerve (CN) VII (facial) by noting facial symmetry. Have the patient frown, smile, puff out their cheeks, and raise their eyebrows. Expressions should be symmetrical; Bell's palsy causes drooping of the upper and lower face; cerebrovascular accident (CVA) causes asymmetry. Assess cranial nerve CN V (trigeminal) by applying light sensation with a cotton ball to symmetric areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation is possibly due to a CN V lesion or a lesion in higher sensory pathways. Assess CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. These cranial nerves are most likely to be affected by increasing intracranial pressure (ICP), which causes a change in pupil response or pupil size; sometimes pupils change shape (more oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and a nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis.

The answer to question 2

B
Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient's risk for falling. Dehydration or edema may require more frequent position changes because patients are prone to skin breakdown.

The answer to question 3

A
In addition to standard precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include gastrointestinal, respiratory, skin, or wound infection and colonization with multidrug-resistant bacteria judged by the infection control program as follows: (1) enteric with a low infectious dose or prolonged environmental survival, including Clostridium difficile, Escherichia coli, Shigella, hepatitis A, or rotavirus; or (2) skin infections that are highly contagious or that may occur on dry skin. Standard precautions apply to blood, all body fluids, secretions, excretions, nonintact skin, and mucous membranes. Patients who may be infected by pathogens that can be spread through direct patient contact may need more. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via the airborne route. In addition to standard precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella, and TB. The patient is not exhibiting signs of infection/colonization by pathogens that can be spread via large particle droplets. In addition to standard precautions, use droplet precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. Examples of such illnesses include invasive Haemophilus influenzae type b disease, pertussis, pneumonic plague, streptococcal pharyngitis, pneumonia, and scarlet fever in infants and young children, as well as mumps, parvovirus B19, and rubella.

The answer to question 4

C
In adults, you can apply reusable and disposable oximeter probes to the earlobe, finger, toe, bridge of the nose, or forehead. For patients with decreased peripheral perfusion, you can apply a forehead sensor. Conditions that decrease arterial blood flow such as peripheral vascular disease, hypothermia, pharmacologic vasoconstrictors, hypotension, or peripheral edema affect accurate determination of oxygen saturation in these areas.
poopy199 Author
wrote...
6 years ago
Makes more sense now, TY
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