The patient is diagnosed with Bell's palsy. The nurse assesses the patient and notices drooping of the patient's right eye and the right side of his mouth
When the functions of the following nerves are compared, the most likely cause of these symptoms would be a dysfunction of the:
a. seventh cranial nerve.
b. trigeminal nerve (CN V).
c. oculomotor nerve (CN III).
d. glossopharyngeal nerve (CN IX).
A
Assess cranial nerve (CN) VII (facial) by noting facial symmetry. Have the patient frown, smile, puff out their cheeks, and raise their eyebrows. Expressions should be symmetrical; Bell's palsy causes drooping of the upper and lower face; cerebrovascular accident (CVA) causes asymmetry. Assess cranial nerve CN V (trigeminal) by applying light sensation with a cotton ball to symmetric areas of the face. Sensations should be symmetric; unilateral decrease or loss of sensation is possibly due to a CN V lesion or a lesion in higher sensory pathways. Assess CN III (oculomotor), IV (trochlear), and VI (abducens) by assessing extraocular movement (EOM) functioning. Ask the patient to follow the movement of your finger through the six cardinal positions of gaze; measure pupillary reaction to light reflex and accommodation using a penlight. These cranial nerves are most likely to be affected by increasing intracranial pressure (ICP), which causes a change in pupil response or pupil size; sometimes pupils change shape (more oval) or react sluggishly. ICP impairs EOMs. Damage to CN IX causes impaired swallowing; damage to CN X causes loss of gag reflex, hoarseness, and a nasal voice. When the palate fails to rise and the uvula pulls toward the normal side, this indicates a unilateral paralysis.
You might also like to view...
If the coefficient alpha for a stress scale was computed to be 0.80, the scale would be:
A) Of less acceptable reliability than a scale with an alpha of 0.50 B) A valid indicator of stress C) Of indeterminate reliability until the scale's test–retest reliability was assessed D) Of acceptably high reliability
A client receiving renal replacement therapy over 5 years has lost 40 lbs. and has significant muscle wasting. How should the nurse document this finding?
a. Fat catabolism b. Dry weight loss c. Metabolic acidosis d. Protein-energy wasting
Before beginning a teaching-learning session with a patient, the nurse assesses the patient's behavior about learning. This nurse is implementing which of the following theories of learning?
a. Watson c. Skinner b. Pavlov d. Thorndike
The nurse is planning to administer an ertapenem IV to a patient in the intensive care unit. When preparing this medication, the nurse will consider reconstituting it with (Select all that apply.)
a. water. b. bacteriostatic water. c. 0.9% sodium chloride. d. 0.45% dextrose. e. 1% lidocaine.