Which of the ff is a nursing intervention to ensure that the client is free from injury caused by falls?

Correct Answer: B

Rationale: Monitoring for swelling and heaviness of legs is a nursing intervention that can help prevent falls. Swelling and heaviness of legs could indicate conditions such as edema or circulation problems, which may increase the risk of falls due to impaired mobility and stability. By identifying these signs early on, the nurse can intervene promptly to address the underlying issues and prevent potential falls. This proactive approach aligns with the goal of ensuring the client is free from injury caused by falls. Monitoring for chest pain and elevated low-density lipoprotein levels, postural changes in BP, or mild fever may be important for overall client care but are not directly related to fall prevention.

Correct Answer: C

Rationale: When a neurologist asks a patient to smile, they are testing the function of the facial nerve, Cranial Nerve VII (CN VII). CN VII controls the muscles of facial expression, including the muscles required for smiling. If there is weakness or paralysis on one side of the face when the patient tries to smile, it may indicate a problem with CN VII function, such as Bell's palsy or a lesion affecting the facial nerve.

Correct Answer: D

Rationale: Bell's Palsy is a condition that affects the facial nerve, leading to weakness or paralysis of the facial muscles. One common complication of Bell's Palsy is the inability to fully close the affected eye, which can result in corneal exposure and dryness. Lubricating eye drops help prevent dryness and protect the cornea from damage due to inadequate eye closure. Using lubricating eye drops regularly can help maintain the eye's moisture and prevent potential complications such as corneal abrasions and infections, which are common in patients with Bell's Palsy. Megavitamin therapy, application of ice, and elastic bandages are not typically indicated for preventing complications in patients with Bell's Palsy.

Correct Answer: A

Rationale: The most reliable index of cerebral state in a patient diagnosed with a brain tumor and concerning increased intracranial pressure is the level of consciousness. Changes in consciousness, such as alterations in alertness, orientation, and responsiveness, are significant indicators of the brain's functioning and can provide valuable insights into the impact of increased intracranial pressure. Monitoring the level of consciousness helps healthcare providers assess neurological status and make critical decisions regarding the management of intracranial pressure. Unilateral papillary dilatation, increased systolic blood pressure, and decreased pulse pressure may also be important indicators but are not as reliable or direct as changes in the level of consciousness when evaluating cerebral status in this context.

Correct Answer: B

Rationale: In this scenario, the correct documentation would be "B) PERRLA" which stands for Pupils Equal, Round, React to Light, and Accommodation. This abbreviation is used to document the findings of the pupillary exam. The other options are incorrect because: A) "Pupils 2 mm" only refers to the size of the pupils and does not cover all aspects of the pupillary exam. C) "Pupils constricted" is too vague and does not include all the necessary elements of the exam. D) "Pupils normal" does not provide a comprehensive description of the findings observed during the exam. Educationally, understanding how to document pupillary exam findings accurately is crucial in healthcare, especially in critical care settings like pediatric care where subtle changes in pupillary responses can indicate neurological issues. By using standardized abbreviations like PERRLA, healthcare providers can effectively communicate and document their findings for proper patient assessment and care planning.