The 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?

"You may be able to prevent Bell's palsy by doing facial exercises regularly."

"Medications to treat Bell's palsy work only if started before paralysis onset."

"Call the doctor if you experience pain or develop herpes lesions near the ear."

"Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy."

Answer and Explanation

The Correct Answer is C

A. "You may be able to prevent Bell's palsy by doing facial exercises regularly." Regular facial exercises have not been proven to prevent Bell's palsy. In fact, excessive facial exercises could potentially exacerbate symptoms in some cases.

B. "Medications to treat Bell's palsy work only if started before paralysis onset." While early treatment with antiviral medications may be beneficial in some cases, it is not accurate to say that medications only work if started before paralysis onset. Treatment can still be effective even after the onset of symptoms, although it may not be as effective as when started early.

C. "Call the doctor if you experience pain or develop herpes lesions near the ear." This is important information because Bell's palsy has been associated with reactivation of the herpes simplex virus. Pain or the development of herpes lesions near the ear could indicate impending or active Bell's palsy, and prompt medical evaluation is necessary.

D. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." While antiviral medications can reduce the risk of herpes simplex virus reactivation, there is no guarantee that prophylactic treatment will prevent Bell's palsy. However, prompt treatment of herpes outbreaks may help reduce the risk.

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Correct Answer is A

Explanation

A. Turn the client's head to the side: This action helps prevent aspiration by allowing any oral secretions or vomitus to drain out of the mouth, reducing the risk of airway obstruction and aspiration pneumonia.

B. Loosen the clothing around the client's waist: While it's important to ensure the client's safety during a seizure, addressing airway protection takes precedence over loosening clothing. Loosening clothing can be done after ensuring airway patency.

C. Document the time the seizure began: Documenting the time of onset is important for accurately assessing the duration of the seizure, but it is not the first action to take during an active seizure.

D. Check the client's motor strength: Assessing motor strength is important for evaluating the
client's condition after the seizure has ended, but it is not the first action to take during an active seizure. Ensuring airway protection and preventing injury are the priorities during the seizure.

A. Start a labetalol drip to keep BP less than 140/90 mm Hg. B. Keep the head of the bed elevated at least 30 degrees. C. Begin tissue plasminogen activator (tPA) intravenously per protocol. D. Infuse normal saline intravenously at 75 mL/hr.

Correct Answer is C

Explanation

A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.

B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.

C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.

D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.

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The 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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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