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?
Inability to perform within normal limits
Symmetrical findings
Asymmetrical findings
Bilateral strength present
The Correct Answer is C
Choice A Reason: This choice is incorrect. Inability to perform within normal limits is a vague and general term that does not describe the specific finding of left facial droop. The nurse should document the exact observation and compare it to the expected or normal range.
Choice B Reason: This choice is incorrect. Symmetrical findings mean that both sides of the body or face are equal or similar in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is not symmetrical.
Choice C Reason: This is the correct choice. Asymmetrical findings mean that both sides of the body or face are unequal or different in appearance or function. Left facial droop indicates that one side of the face is lower or weaker than the other, which is asymmetrical.
Choice D Reason: This choice is incorrect. Bilateral strength present means that both sides of the body or face have normal or adequate muscle power or force. Left facial droop indicates that one side of the face has reduced or impaired muscle power or force, which is not bilateral strength present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This is incorrect because Ménière's disease is not caused by an allergic response. Ménière's disease is a disorder of the inner ear that causes vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. The exact cause of Ménière's disease is unknown, but it may be related to fluid imbalance, infection, trauma, or autoimmune reaction.
Choice B Reason: This is correct because diphenhydramine can help offset the nauseous feeling. Diphenhydramine is an antihistamine that blocks histamine receptors in the brain and inner ear, which can reduce nausea and vomiting associated with vertigo.
Choice C Reason: This is correct because anticholinergics will help you rest. Anticholinergics are a class of drugs that block acetylcholine receptors in the brain and body, which can have sedative effects and reduce motion sickness. Diphenhydramine has anticholinergic properties.
Choice D Reason: This is correct because diphenhydramine can help reduce vomiting episodes. As mentioned above, diphenhydramine can reduce nausea and vomiting by blocking histamine receptors in the brain and inner ear.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because encouraging coughing and deep breathing can increase intracranial pressure (ICP), which is the pressure inside
the skull that can affect brain function. Coughing and deep breathing can increase blood flow and oxygen demand to the brain, which can worsen cerebral edema. The nurse should suction the patient as needed and maintain a patent airway.
Choice B Reason: This is incorrect because positioning the patient with knees and hips flexed can increase ICP by reducing venous drainage from the head. The nurse should position the patient with neck and body in alignment and avoid extreme flexion or extension of any joints.
Choice C Reason: This is incorrect because performing nursing interventions once an hour can disturb the patient's sleep and increase ICP by stimulating brain activity. The nurse should cluster nursing interventions and provide quiet and dark environment to promote rest and reduce stress.
Choice D Reason: This is correct because keeping the head of the bed elevated to 30 degrees can decrease ICP by facilitating venous drainage from the head and reducing cerebral blood volume. The nurse should monitor the patient's blood pressure and pulse to ensure adequate cerebral perfusion.
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