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AndyWang AndyWang
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Posts: 366
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6 years ago
Which assessment data for a patient who has Guillain-Barr syndrome will require the nurse's most immediate action?
 
  a. The patient's triceps reflexes are absent.
  b. The patient is continuously drooling saliva.
  c. The patient complains of severe pain in the feet.
  d. The patient's blood pressure (BP) is 150/82 mm Hg.

Question 2

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia?
 
  a. Support selection of a high-protein diet.
  b. Discuss options for sexuality and fertility.
  c. Assist in planning a prescribed bowel program.
  d. Use quad coughing to strengthen cough efforts.

Question 3

A 32-year-old pregnant patient with Bell's palsy refuses to eat while others are present because of embarrassment about drooling. The best response by the nurse is to
 
  a. respect the patient's feelings 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.

Question 4

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?
 
  a. You may be able to prevent Bell's palsy by doing facial exercises regularly.
  b. Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy.
  c. Medications to treat Bell's palsy work only if started before paralysis onset.
  d. Call the doctor if you experience pain or develop herpes lesions near the ear.

Question 5

Which action should the nurse take when assessing a patient with trigeminal neuralgia?
 
  a. Have the patient clench the jaws.
  b. Inspect the oral mucosa and teeth.
  c. Palpate the face to compare skin temperature bilaterally.
  d. Identify trigger zones by lightly touching the affected side.
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Replies
wrote...
6 years ago
The answer to question 1

ANS: B
Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barr syndrome.

The answer to question 2

ANS: C
Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

The answer to question 3

ANS: A
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 answer to question 4

ANS: D
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.

The answer to question 5

ANS: B
Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
AndyWang Author
wrote...
6 years ago
Thank you soooo very much, it was really helpful and kind of you to answer my q's
wrote...
6 years ago
You're welcome, once again
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