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 D
Explanation
A. While age contributes to hypertension risk, being male and 53 years old does not inherently confer the greatest risk when compared to other factors like ethnicity.
B. The client’s younger age and female gender reduce the overall risk for hypertension compared to other groups.
C. Although people of Asian ethnicity can develop hypertension, their overall risk is lower than that of African Americans.
D. African Americans have a significantly higher risk for hypertension due to a combination of genetic, environmental, and socio-economic factors. This group is known to have a higher prevalence of this condition, often developing it at an earlier age.
Correct Answer is C
Explanation
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.