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D drooling is present on right side of the mouth but

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d-Drooling is present on right side of the mouth, but not on theleft.Rationale:Because the motor function controlling eye closure, browmovement and smiling are all carried on the 7thcranial (facial) nerve, thecombination of symptoms directly relating to an impairment of allStuvia.com - The Marketplace to Buy and Sell your Study MaterialDownloaded by: ericalamb78 | [email protected]Distribution of this document is illegal
Stuvia.com - The Marketplace to Buy and Sell your Study Materialbranches of the facial nerve indicate that Bell‟s palsy has occurred.102-The nurse is teaching a client how to perform colostomyirrigations. When observing the client‟s return demonstration,which action indicated that the client understood the teaching?a-Turns to left the side to instill the irrigating solution into thestomab-Keeps the irrigating container less than 18 inches abovethe stomac-Instills 1,200 ml of irrigating solution to stimulate bowelevacuationd-Inserts irrigating catheter deeper into stoma when crampingoccursRationale: Keeping the irrigating container less than 18 inchesabove the stoma permits the solution to flow slowly with littleexcessive peristalsis does not cause immediate release of stool.103-The nurse should teach the client to observe which precautionwhile taking dronedarone?Stuvia.com - The Marketplace to Buy and Sell your Study MaterialDownloaded by: ericalamb78 | [email protected]Distribution of this document is illegal
Stuvia.com - The Marketplace to Buy and Sell your Study Materiala-Stay out of direct sunlightb-Avoid grapefruits and its juicec-Reduce the use of herbal supplementsd-Minimize sodium intake.Rationale: Grapefruit increase the effect of dronedarone therebyincreasing the possibility of serious side effects. A does not cause aserious effect. C may potentiate lethal arrhythmias and should beavoided. D does not directly affect those taking dronedarone.104-A client who sustained a head injury following an automobilecollision is admitted to the hospital. The nurse includes theclient‟s risk for developing increased intracranial pressure(ICP)in the plan of care. Which signs indicate to the nurse that ICP hasincreased?a-Increased Glasgow coma scale score.b-Nuchal rigidity and papilledema.c-Confusion and papilledemad-Periorbital ecchymosis.Rationale: papilledema is always an indicator of increased ICP, andconfusion is usually the first sign of increased ICP. Other options do notnecessarily reflect increased ICP.Stuvia.com - The Marketplace to Buy and Sell your Study MaterialDownloaded by: ericalamb78 | [email protected]Distribution of this document is illegal
Stuvia.com - The Marketplace to Buy and Sell your Study Material105-The nurse is caring for a client receiving continuous IV fluidsthrough a single lumen central venous catheter (CVC). Based onthe CVC care bundle, which action should be completed daily toreduce the risk for infection?

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Term
Fall
Professor
N/A
Tags
Nursing, Blood sugar, UAP, main rationale, The Grave,

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