A client with a new diagnosis of trigeminal neuralgia is receiving education to prevent triggering an acute onset. Which of the following will the nurse include in teaching?

Massage the affected side multiple times a day.

Apply ice directly to the skin.

Provide pureed consistency foods.

Consider alternative therapies such as yoga, biofeedback, or meditation.

Answer and Explanation

The Correct Answer is D

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

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Correct Answer is ["E","F"]

Explanation

Choice A Reason: This is incorrect because submerging the client in a cold bath can cause hypothermia, shock, or infection. Cold water can lower the body temperature and blood pressure, which can impair circulation and organ function. Cold water can also introduce bacteria or contaminants into the open wounds. The nurse should use cool water or saline to gently irrigate the burned areas and then cover them with sterile dressings.

Choice B Reason: This is correct because administering oxygen can help the client breathe better and prevent hypoxia. Burns to the face, neck, or chest can cause swelling or damage to the airway, which can impair gas exchange and oxygen delivery. Oxygen can also reduce the risk of carbon monoxide poisoning, which can occur from inhaling smoke or fumes.

Choice C Reason: This is incorrect because restricting fluids can worsen dehydration and shock. Burns can cause significant fluid and electrolyte loss through evaporation and leakage from damaged capillaries. This can lead to hypovolemia, which is low blood volume, and hypotension, which is low blood pressure. The nurse should monitor the client's vital signs, urine output, and weight, and administer intravenous fluids as ordered.

Choice D Reason: This is incorrect because providing a meal high in fiber can cause abdominal discomfort or diarrhea. Burns can cause paralytic ileus, which is a temporary loss of bowel function due to nerve damage or inflammation. This can impair digestion and absorption of food and cause nausea, vomiting, or constipation. The nurse should assess the client's bowel sounds and provide enteral or parenteral nutrition as ordered.

Choice E Reason: This is correct because assessing airway is a priority nursing action for a client with burns. As mentioned above, burns to the face, neck, or chest can compromise the airway and cause respiratory distress or failure. The nurse should assess the client's level of consciousness, breathing rate and pattern, oxygen saturation, and signs of inhalation injury, such as sooty sputum, singed nasal hairs, or hoarseness. The nurse should also be prepared to assist with intubation or tracheostomy if needed.

Choice F Reason: This is correct because applying ice to burned areas can help reduce pain and swelling. Ice can constrict blood vessels and numb nerve endings, which can decrease inflammation and sensation. However, ice should be applied for no more than 15 minutes at a time and wrapped in a cloth or towel to prevent frostbite or tissue damage. Ice should not be applied to large or deep burns.

A. Nystagmus B. Decorticate positioning C. Lack of any response D. Decerebrate positioning

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.

Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.

Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.

Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.

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A client with a new diagnosis of trigeminal neuralgia is receiving education to prevent triggering an acute onset. Which of the following will the nurse include in teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (Select all that apply.)

Correct Answer is ["E","F"]

Explanation

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Correct Answer is D

Explanation

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