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 B
Explanation
A. Primary dementia is not characterized by temporary or reversible loss of brain function; it typically involves progressive and irreversible changes.
B. Forgetfulness that gradually progresses to disorientation is a common manifestation of primary dementia, indicating cognitive decline.
C. Hyper vigilant behaviors are not typical of dementia; instead, individuals may exhibit confusion or disorientation.
D. Sleeping more during the day than nighttime is not a specific manifestation of primary dementia and could be attributed to other factors, including other medical conditions or medications.