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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Explanation
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B. The sandbag should be placed over the left groin area where the femoral artery was accessed during the angiography. This helps apply pressure to prevent bleeding from the site and promote clot formation.
C. The right ankle is irrelevant to the procedure and would not require pressure.
D. Similarly, the left ankle has no relation to the femoral angiography site.
Correct Answer is B
Explanation
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B. Protamine sulfate is the specific antidote for heparin and is used to reverse its anticoagulant effects in cases of overdose or when surgery is needed.
C. Vitamin K is used to reverse the effects of anticoagulants like warfarin, not heparin, making it incorrect in this context.
D. Deferoxamine is used to treat iron toxicity and has no relevance to heparin reversal, making this option incorrect.