A client has a patch test performed with the following results. Which of the following is the best response the nurse will offer the client regarding the observations from the test?

Choice A reason: This is incorrect because the nurse should not include this in teaching. Massaging the affected side multiple times a day can trigger an acute onset of trigeminal neuralgia. Trigeminal neuralgia is a condition that causes severe pain in one or more branches of the trigeminal nerve (cranial nerve V), which innervates the face. The pain can be triggered by touch, pressure, or movement of the face. The nurse should advise the client to avoid touching or stimulating the affected side.

Choice B reason: This is incorrect because the nurse should not include this in teaching. Applying ice directly to
the skin can trigger an acute onset of trigeminal neuralgia. Trigeminal neuralgia can be triggered by temperature changes or cold stimuli on the face. The nurse should advise the client to avoid exposure to cold air or wind and to protect their face with a scarf or mask.

Choice C reason: This is incorrect because the nurse should not include this in teaching. Providing pureed consistency foods can trigger an acute onset of trigeminal neuralgia. Trigeminal neuralgia can be triggered by chewing, swallowing, or talking. The nurse should advise the client to eat soft foods that do not require much chewing and to avoid hot or spicy foods that can irritate the mouth.

Choice D reason: This is correct because the nurse should include this in teaching. Considering alternative therapies such as yoga, biofeedback or meditation can help prevent triggering an acute onset of trigeminal neural

Choice A reason: This is the correct answer because airway obstruction is the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Airway obstruction can occur due to edema, inflammation, or inhalation injury of
the upper airway structures. It can compromise oxygenation and ventilation, and lead to respiratory failure or cardiac arrest. The nurse should assess for signs of airway obstruction, such as stridor, hoarseness, dyspnea, or cyanosis, and provide oxygen therapy, humidification, or intubation as needed.

Choice B reason: This is incorrect because fluid imbalance is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Fluid imbalance can occur due to fluid loss from damaged skin and capillaries, as well as increased capillary permeability and fluid shifts. It can cause dehydration, hypovolemia, shock, or electrolyte imbalances. The nurse should monitor fluid status, vital signs, urine output, and laboratory values, and provide fluid resuscitation as prescribed, but only after ensuring airway patency.

Choice C reason: This is incorrect because paralytic ileus is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Paralytic ileus is a condition where there is decreased or absent bowel motility due to nerve damage or decreased blood flow to
the gastrointestinal tract. It can cause abdominal distension, nausea, vomiting, or constipation. The nurse should assess bowel sounds, abdominal girth, and stool characteristics, and provide nasogastric suction or laxatives as prescribed, but only after ensuring airway patency and fluid balance.

Choice D reason: This is incorrect because infection is not the risk that is the priority for assessment and intervention for a client who has extensive partial and full-thickness burns of
the head, neck, and chest. Infection can occur due to loss of skin barrier, exposure to microorganisms, or impaired immune system. It can cause fever, increased pain, purulent drainage, or sepsis. The nurse should assess for signs of infection, obtain wound cultures, and administer antibiotics as prescribed, but only after ensuring airway patency, fluid balance, and pain control.