ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 63 Questions
Question 1 of 5
The nurse is assessing a patient with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess?
Correct Answer: A
Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
Question 2 of 5
Which of the following actions should the nurse take when assessing a patient with trigeminal neuralgia?
Correct Answer: A
Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
Question 3 of 5
The nurse is caring for a patient with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement?
Correct Answer: C
Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
Question 4 of 5
Which of the following actions should the nurse include in the plan of care for a patient who is experiencing trigeminal neuralgia?
Correct Answer: B
Rationale: The patient with an acute episode of trigeminal neuralgia may be unwilling to eat or drink, so assessment of nutritional and hydration status is important. Because stimulation by touch is the precipitating factor for pain, relaxation of the facial muscles will not improve symptoms. Application of ice is likely to precipitate pain. The patient will not want to engage in conversation, which may precipitate attacks.
Question 5 of 5
The nurse is teaching a patient who is at risk for Bell's palsy because of previous herpes simplex infection. Which of the following information should the nurse include?
Correct Answer: A
Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.