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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.)

A.

Pain behind the ear

B.

Muscle distortion

C.

Facial twitching

D.

Impaired taste

E.

Hearing loss

Question Solution

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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View Related questions

Correct Answer is ["C","D","E"]

Explanation

A. Restraints should not be used routinely for clients with seizure disorders, as they can lead to injury and are not recommended for seizure management.

B. A bite stick is not recommended during a seizure because it can cause injury to the client’s teeth and jaw.

C. Keeping an oxygen setup at the bedside is essential to provide supplemental oxygen if the client experiences difficulty breathing during or after a seizure.

D. Elevating the side rails when the client is in bed helps prevent falls and injuries during a seizure, providing a safer environment.

E. A suction setup at the bedside is important to clear secretions and prevent aspiration during a seizure, especially if the client has impaired swallowing or is at risk for aspiration.

Correct Answer is C

Explanation

A. The recommended sodium intake for individuals with hypertension is typically less than 2,300 mg per day, so a goal of 3,000 mg is too high.

B. For individuals with hypertension, it is recommended to limit alcohol consumption to 1 drink per day for women and 2 drinks per day for men, so 3 drinks is excessive.

C. Planning to have potassium blood levels checked when taking thiazide diuretics is important because these medications can lead to hypokalemia (low potassium levels), making this the correct response.

D. Setting a goal body weight within 25% of ideal body weight is not a standard recommendation; weight management should focus on achieving a healthy weight, rather than a specific percentage of ideal body weight.

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