A patient presents to the Emergency Department (ED) reporting right facial weakness. The nurse understands that a patient suffering from Bell's Palsy will exhibit which assessment findings related to the cranial nerve involvement?

painful areas on the affected side following 3 branches of the nerve

decreased visual acuity when tested with Snellen Chart

unilateral upper and lower facial weaknesses including forehead

facial dropping, with arm and leg weakness on the affected side

Answer and Explanation

The Correct Answer is C

A) Painful areas on the affected side following 3 branches of the nerve:
This is not typically a feature of Bell's Palsy. Bell's Palsy is primarily a motor dysfunction of the facial nerve (cranial nerve VII), leading to facial weakness. The pain associated with Bell's Palsy, if present, is usually mild and localized to the jaw, behind the ear, or along the jawline rather than along all three branches of the trigeminal nerve (cranial nerve V), which controls sensation in the face. Therefore, this choice is not consistent with the typical presentation of Bell's Palsy.

B) Decreased visual acuity when tested with Snellen Chart:
Decreased visual acuity is not a primary feature of Bell's Palsy. This condition specifically affects facial nerve function, which controls the muscles of facial expression, including those responsible for closing the eyes tightly. However, Bell's Palsy does not typically result in visual changes such as decreased visual acuity or problems with vision itself. Decreased vision would be more indicative of an issue with the optic nerve (cranial nerve II) or other eye-related conditions.

C) Unilateral upper and lower facial weakness including forehead:
This is the hallmark sign of Bell's Palsy. The facial nerve (cranial nerve VII) controls the muscles of the face, and when it becomes affected by Bell's Palsy, both the upper and lower parts of the face on one side can be weak or paralyzed. Importantly, Bell's Palsy causes inability to wrinkle the forehead, which distinguishes it from stroke, where the forehead is typically spared because the upper part of the facial muscles receives bilateral input from the brain. Thus, both upper and lower facial weakness, including inability to raise the eyebrow (forehead), is characteristic of Bell's Palsy.

D) Facial dropping, with arm and leg weakness on the affected side:
Facial drooping is a common symptom of Bell's Palsy, but arm and leg weakness is not associated with it. Arm and leg weakness on the same side would be more suggestive of a stroke affecting the cerebrovascular system, rather than a peripheral nerve issue like Bell's Palsy. Bell's Palsy is confined to facial nerve dysfunction and does not cause weakness in the limbs.

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Correct Answer is C

Explanation

A) Take this medication as needed for pain:
Baclofen is a muscle relaxant typically prescribed for managing spasticity associated with multiple sclerosis (MS), rather than for pain. It should be taken as prescribed, typically on a scheduled basis rather than on an as-needed basis for pain. Misunderstanding this could lead to improper use of the medication and ineffective symptom management.

B) Stop the medication if I experience dry mouth:
Dry mouth is a potential side effect of baclofen, but it should not be the reason to stop the medication abruptly. Stopping baclofen suddenly can result in withdrawal symptoms and could potentially worsen spasticity. If dry mouth or other side effects are bothersome, the client should consult the healthcare provider for management options rather than discontinuing the medication abruptly.

C) Taper this medication off over 1-2 weeks:
This statement demonstrates a correct understanding of the proper way to discontinue baclofen. Baclofen should not be stopped suddenly due to the risk of withdrawal symptoms, which can include increased spasticity, hallucinations, or seizures. A gradual tapering of the dose over a period of 1 to 2 weeks is recommended to avoid withdrawal. This is the most appropriate and safe response.

D) Feel an increase in energy with this medication:
Baclofen is not a medication designed to increase energy. Its primary purpose is to reduce muscle spasticity, not to provide a stimulant effect. If the client expects an increase in energy, this could indicate a misunderstanding of the medication's effects. Baclofen's focus is on reducing spasticity and muscle tightness, not improving energy levels.

A. Prepare for chest tube insertion B. Chart assessment findings C. Administer lorazepam D. Initiate IV fluid resuscitation

Correct Answer is A

Explanation

A) Prepare for chest tube insertion:
The priority treatment for a hemothorax, which is a collection of blood in the pleural space, is to address the loss of intravascular volume and to relieve the pressure on the lungs. The insertion of a chest tube is the first step in draining the blood and restoring proper lung function and ventilation. This intervention directly addresses the cause of obstructive shock (increased pressure on the lungs and impaired cardiac output) by re-expanding the lung and preventing further complications such as respiratory distress or cardiovascular collapse.

B) Chart assessment findings:
While accurate documentation of the patient's condition is important for ongoing care and legal purposes, it is not the priority action in this situation. Immediate treatment to address the hemothorax, such as chest tube insertion, takes precedence over documentation. Charting should be done after stabilizing the patient.

C) Administer lorazepam:
Lorazepam is an anxiolytic medication that might be used for anxiety or agitation, but it is not an immediate priority in this situation. The patient's life-threatening condition (hemothorax) needs to be addressed first, and sedation or anxiety management should be considered once the patient is stabilized and receiving appropriate interventions.

D) Initiate IV fluid resuscitation:
While fluid resuscitation is essential in trauma patients with hypovolemic shock, the primary concern in hemothorax is relieving the intrathoracic pressure by draining the blood from the pleural space. IV fluid resuscitation should be initiated shortly after or simultaneously with the chest tube insertion, but addressing the hemothorax directly is the first priority in treating obstructive shock.

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A patient presents to the Emergency Department (ED) reporting right facial weakness. The nurse understands that a patient suffering from Bell's Palsy will exhibit which assessment findings related to the cranial nerve involvement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing education to the client diagnosed with multiple sclerosis (MS) about baclofen. What statement made by the client would indicate to the nurse that the client understood the education? The client states ‘’I will

Correct Answer is C

Explanation

A nurse is assisting the provider to care for trauma patient who has been diagnosed with a hemothorax. Which of the following actions should the nurse perform first to treat this cause of obstructive shock?

Correct Answer is A

Explanation

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