A patient is diagnosed with Bell's palsy and has signs of unilateral facial paralysis and is unable to close his right eye. What eye care is required?

Correct Answer: A

Rationale: In the case of a patient diagnosed with Bell's palsy exhibiting signs of unilateral facial paralysis and the inability to close the affected eye, the correct eye care required is to instill artificial teardrops and use an eye patch (Option A). This care is essential to prevent complications such as corneal abrasions due to inadequate eye closure and dryness. Explanation of options: - Option B is incorrect as Bell's palsy symptoms may take weeks to months to resolve, and neglecting proper eye care can lead to eye complications. - Option C, increasing fluid intake, does not address the need for artificial tears to prevent dryness and protect the cornea. - Option D, wearing sunglasses, does not adequately address the issue of protecting the eye from dryness and exposure, as an eye patch is more effective in maintaining moisture and preventing damage. Educational context: It is crucial to provide proper eye care in patients with Bell's palsy to prevent ocular complications. The inability to close the eye fully can lead to dryness, exposure, and potential damage to the cornea. Artificial tears help maintain moisture, while an eye patch protects the eye from external elements. This care regimen is essential until the patient's facial nerve function improves to prevent long-term eye issues.

Correct Answer: C

Rationale: In the context of a patient with a CD4 count less than 200, which indicates severe immunosuppression typically seen in advanced HIV/AIDS, the most crucial nursing assessment would be monitoring for fever (Option C). This is because a low CD4 count puts the patient at high risk for opportunistic infections. Fever is often the first sign of an infection in these patients and can indicate a serious systemic response. Option A, bowel movements, while important for overall health assessment, is not the priority in this case as it does not directly correlate with the patient's immunosuppressed status and infection risk. Option B, urinary output, is also important but does not take precedence over monitoring for signs of infection in a patient with such a low CD4 count. Option D, blood pressure, is not the priority in this situation unless the patient is showing signs of sepsis, which would typically present with a fever. Understanding the priority assessments based on the patient's condition is crucial in providing effective and targeted care in medical-surgical settings, especially in patients with complex health conditions like advanced HIV/AIDS.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Heavy menses or an inadequate intake of iron. Iron deficiency anemia is commonly caused by chronic blood loss, such as heavy menstrual periods, which leads to a decreased iron supply for the body. Option A) Insomnia is unrelated to the development of iron deficiency anemia. Option B) An increase in iron intake would actually be beneficial in preventing iron deficiency anemia, so this option is incorrect. Option D) Low salt intake is not a common cause of iron deficiency anemia. From an educational standpoint, it is important for students to understand the etiology of iron deficiency anemia to provide appropriate care and education to patients. By knowing the causes, nurses can implement interventions such as iron supplementation or dietary changes to help manage and prevent iron deficiency anemia in patients like Anne. This question also reinforces the importance of recognizing common risk factors for iron deficiency anemia in clinical practice.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) The left side of your heart is weakened and is losing the capability to pump blood to your lungs. This is because congestive heart failure typically involves the left side of the heart being unable to effectively pump blood to the rest of the body, causing fluid to back up into the lungs. Option A is incorrect because fluid accumulation in the lungs is not primarily due to the volume of IV fluid administered but rather to the heart's inability to pump effectively. Option B is incorrect as it mentions the right side of the heart, which is not typically associated with fluid accumulation in the lungs in congestive heart failure. Option C is unrelated to the pathophysiology of congestive heart failure and is therefore incorrect. Educationally, understanding the underlying pathophysiology of congestive heart failure is crucial for providing appropriate care and education to patients. By knowing why fluid accumulates in the lungs, healthcare providers can better explain the condition to patients like Tom and help them manage their symptoms effectively. This knowledge also aids in delivering patient-centered care and promoting patient compliance with treatment plans.

Correct Answer: B

Rationale: In a patient with peritonitis, the correct assessment findings would include rebound tenderness and guarding. Rebound tenderness refers to pain felt upon the sudden release of pressure on the abdomen, indicating peritoneal irritation. Guarding is the involuntary contraction of the abdominal muscles in response to pain, which is a protective mechanism. These signs suggest inflammation of the peritoneum, a key feature of peritonitis. Option A is incorrect because a soft abdomen with normal bowel sounds is not indicative of peritonitis. Option C is incorrect because hyperactive bowel sounds are not typically associated with peritonitis; instead, bowel sounds may be diminished. Option D is incorrect as ascites and increased vascular pattern on the skin are not specific to peritonitis. Educationally, understanding these assessment findings is crucial for nurses and healthcare providers to recognize peritonitis promptly and initiate appropriate interventions. This knowledge is vital for patient safety and optimal outcomes, highlighting the importance of clinical assessment skills in the medical-surgical setting.