A patient with Bell's palsy is admitted to the unit. Which nursing intervention demonstrates strategic planning to prevent complications related to impaired facial muscle function?

• Encourage the patient to perform facial exercises only once daily.

• Teach the patient to use artificial tears and tape the eyelid closed at night.

• Advise the patient to avoid all oral intake until facial function returns.

• Instruct the patient to sleep only on the affected side.

Answer explanation

Teaching the patient to use artificial tears and tape the eyelid closed at night addresses the risk of corneal injury due to impaired eyelid closure, demonstrating effective planning to prevent complications from Bell's palsy.

A patient with trigeminal neuralgia reports severe facial pain triggered by brushing teeth. Which nursing action is most appropriate to minimize pain episodes?

• Recommend the use of a hard-bristled toothbrush.

• Suggest the patient avoid all oral hygiene practices.

• Advise the use of lukewarm water and a soft-bristled toothbrush.

• Encourage frequent chewing of gum.

Answer explanation

Advising the use of lukewarm water and a soft-bristled toothbrush minimizes irritation and discomfort during oral hygiene, which is crucial for patients with trigeminal neuralgia who experience pain from stimuli.

A patient with Huntington's disease is experiencing difficulty swallowing. Which nursing intervention should be prioritized to reduce the risk of aspiration?

• Offer large meals three times a day.

• Position the patient upright during and after meals.

• Provide thin liquids to facilitate swallowing.

• Encourage the patient to eat quickly.

Answer explanation

Positioning the patient upright during and after meals helps prevent aspiration by allowing gravity to assist in swallowing and reducing the risk of food or liquid entering the airway.

A nurse is caring for a patient with ALS who is experiencing progressive muscle weakness. Which strategic intervention should the nurse implement to maintain the patient’s independence?

• Restrict all physical activity to prevent fatigue.

• Collaborate with physical therapy for assistive device training.

• Encourage the patient to perform strenuous exercises.

• Delay introduction of adaptive equipment until weakness is severe.

Answer explanation

Collaborating with physical therapy for assistive device training helps the patient with ALS maintain independence by providing tools that support mobility and daily activities, rather than restricting activity or delaying necessary adaptations.

Tags

NGSS.HS-ETS1-2

A patient with Parkinson’s disease is at risk for falls due to shuffling gait and postural instability. Which nursing action best demonstrates strategic planning to reduce fall risk?

• Place the patient’s bed in the highest position.

• Remove all assistive devices from the room.

• Implement scheduled toileting and keep pathways clear.

• Encourage the patient to walk without supervision.

Answer explanation

Implementing scheduled toileting and keeping pathways clear addresses the patient's risk factors by minimizing the need for sudden movements and ensuring a safe environment, thus effectively reducing fall risk.

A patient with myasthenia gravis is admitted with increasing muscle weakness. Which nursing intervention is most appropriate to prevent respiratory compromise?

• Schedule all activities in the evening.

• Monitor respiratory status and administer medications before meals.

• Encourage the patient to skip doses of anticholinesterase drugs.

• Limit communication with the patient to reduce fatigue.

Answer explanation

Monitoring respiratory status and administering medications before meals is crucial for patients with myasthenia gravis to prevent respiratory compromise, as it ensures optimal muscle function during eating and reduces the risk of aspiration.

A patient with multiple sclerosis (MS) reports new onset of blurred vision and muscle weakness. Which nursing action should be prioritized to evaluate disease progression?

• Advise the patient to ignore symptoms and rest.

• Document symptoms and notify the healthcare provider for further assessment.

• Instruct the patient to increase physical activity immediately.

• Delay reporting symptoms until the next scheduled visit.

Answer explanation

Documenting symptoms and notifying the healthcare provider is crucial for assessing disease progression in MS. This ensures timely evaluation and intervention, rather than ignoring symptoms or delaying reporting.

A patient with Guillain-Barré syndrome (GBS) is experiencing ascending paralysis. Which nursing intervention is most critical to prevent life-threatening complications?

• Monitor for changes in respiratory status and prepare for possible intubation.

• Encourage the patient to ambulate independently.

• Restrict all visitors to prevent infection.

• Delay assessment of vital signs until paralysis resolves.

Answer explanation

In Guillain-Barré syndrome, ascending paralysis can lead to respiratory failure. Monitoring respiratory status and preparing for intubation is critical to prevent life-threatening complications.

A nurse is evaluating the effectiveness of interventions for a patient with Bell’s palsy. Which finding indicates successful nursing care?

• The patient reports persistent eye dryness.

• The patient demonstrates ability to close the affected eyelid.

• The patient refuses to perform facial exercises.

• The patient develops oral ulcers.

Answer explanation

The ability to close the affected eyelid indicates improved muscle control and function, which is a key goal in managing Bell's palsy. This finding shows that the nursing interventions are effective.

A patient with trigeminal neuralgia is receiving carbamazepine therapy. Which laboratory value should the nurse monitor most closely to detect a serious adverse effect of this medication?

• White blood cell count

• Serum potassium level

• Blood glucose level

• Serum calcium level

Answer explanation

Carbamazepine can cause agranulocytosis, a serious adverse effect. Therefore, monitoring the white blood cell count is crucial to detect any significant drop in white blood cells, indicating potential bone marrow suppression.