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 2Which 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 3A 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 4The 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 5Which 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.