A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply)

Impaired taste

Pain behind the ear.

Muscle distortion

Facial twitching

Hearing loss

Answer and Explanation

Correct Answer : A,B,C

A.   Impaired taste is a common symptom of Bell's palsy due to the involvement of the facial nerve, which carries taste fibers.
B.   Pain behind the ear is described as a sharp or aching pain. It is a precursor to facial weakness in many cases.
C.   As the facial muscles become weak or paralyzed, it leads to a distorted appearance, such as drooping of the eyelid or mouth.
D.   Facial twitching is not a typical symptom of Bell's palsy; instead, the muscles are weakened.
E.   Hearing loss is not a typical symptom of Bell's palsy.

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Correct Answer is B

Explanation

A. This would be overwhelming for a client with global aphasia, as they have difficulty processing information.
B. This is the correct approach. Breaking down information into smaller, manageable chunks makes it easier for the client to understand.
C. While consistency is important, limiting communication to one method can be restrictive. It's better to use a variety of techniques (verbal, nonverbal, written, etc.) to support understanding.
D. This can be limiting and frustrating for the client. It's essential to encourage all forms of communication, even if it's difficult.

A. Elevate the head of the bed. B. Provide a brightly lit environment. C. Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day. D. Teach controlled coughing and deep breathing.

Correct Answer is A

Explanation

A. Elevating the head of the bed is a cornerstone of managing increased intracranial pressure (ICP). Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, helping to reduce ICP.
B. A brightly lit environment can stimulate the patient and increase ICP. A calm, dark environment is preferred.
C. Fluid restriction, not encouragement, is often necessary to manage ICP. Excessive fluid can increase intracranial volume.
D. Controlled coughing and deep breathing are important for lung expansion but coughing and straining can increase ICP. Gentle breathing exercises are preferred.

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A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply)

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