When performing an assessment, the nurse observes for bilateral equality. After performing a neurological assessment, which of the following will the nurse document when assessment findings indicate that there is left facial droop?

Choice A reason: This is incorrect because increasing her voice when speaking to the client may not prevent complications, but rather annoy or offend the client. The nurse should not assume that a client with a visual impairment has a hearing impairment as well unless it is confirmed by assessment or history. The nurse should speak in a normal tone and volume and identify herself by name and role.
Choice B reason: This is incorrect because lowering the bed rails before lowering the bed may increase the risk of complications, such as falls or injuries. The nurse should keep the bed rails up until the client is ready to get out of bed and lower them only when necessary. The nurse should also lock the wheels of the bed and adjust it to a comfortable height for the client.
Choice C reason: This is incorrect because using hand gestures to point to where the client will walk may not prevent complications, but rather confuse or frustrate the client. The nurse should not use visual cues or gestures that are meaningless to a client with a visual impairment. The nurse should use verbal directions and descriptions instead, such as "The restroom is on your left, about 10 steps away."
Choice D reason: This is correct because standing slightly in front and to one side of the client can prevent complications, such as collisions or falls. The nurse should guide the client by offering her arm or shoulder for support and walking slightly ahead of him or her. The nurse should also warn the client about any obstacles or changes in terrain, such as stairs, doors, or rugs.

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