A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
Pain behind the ear
Muscle distortion
Facial twitching
Impaired taste
Hearing loss
Correct Answer : A,B,D
A. Pain behind the ear is a common early symptom of Bell's palsy due to inflammation of the facial nerve.
B. Muscle distortion occurs as the facial muscles on the affected side weaken or become paralyzed, leading to an asymmetrical appearance.
C. Facial twitching is not a common manifestation of Bell's palsy; rather, it involves muscle paralysis or weakness.
D. Impaired taste, especially in the anterior two-thirds of the tongue, can occur due to facial nerve involvement.
E. Hearing loss is not typically associated with Bell's palsy; it usually affects facial motor function, not auditory function.
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Correct Answer is ["B","C"]
Explanation
A. Clients with a basilar skull fracture may experience confusion or memory loss regarding the injury, making them unable to recall how it occurred.
B. Pooling of blood around the eyes, known as "raccoon eyes," is a common sign of a basilar skull fracture.
C. Bruising over the mastoid process (Battle's sign) is another classic sign of a basilar skull fracture, indicating trauma to the base of the skull.
D. Chvostek's sign is associated with hypocalcemia, not basilar skull fractures.
Correct Answer is C
Explanation
A. The headache is not related to anxiety but is a known side effect of nitroglycerin due to vasodilation.
B. An allergy to nitroglycerin typically presents as a rash or breathing difficulty, not a headache.
C. Nitroglycerin commonly causes headaches due to the dilation of blood vessels in the brain, which usually lessens over time as the body adjusts.
D. A headache does not indicate tolerance to the medication. Tolerance develops when the body becomes less responsive to the medication's effects, which usually involves a reduced effect on chest pain, not the onset of a headache.