Gwynedd-Mercy College Med Surg 2 exam 2 Nervous
System NCLEX Questions With Complete Solutions
6. A patient with Bell's palsy refuses to eat while others are
present because of embarrassment about drooling. The best
response by the nurse to the patient's behavior is to
a. respect the patient's desire and arrange for privacy at
mealtimes.
b. offer the patient liquid nutritional supplements at frequent
intervals.
c. discuss the patient's concerns with visitors who arrive at
mealtimes.
d. teach the patient to chew food on the unaffected side of the
mouth.
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to
encourage adequate nutrition and reduce patient embarrassment.
Liquid supplements will reduce the patient's enjoyment of the
taste of food. It would be inappropriate for the nurse to discuss
the patient's embarrassment with visitors unless the patient
wishes to share this information. Chewing on the unaffected side
of the mouth will enhance nutrition and enjoyment of food but
will not decrease the drooling.
Cognitive Level: Application Text Reference: p. 1585
Nursing Process: Implementation NCLEX: Psychosocial
Integrity
,2. During assessment of the patient with a recurrence of
symptoms of trigeminal neuralgia, the nurse should
a. examine the mouth and teeth thoroughly.
b. have the patient clench and relax the jaw and eyes.
c. identify trigger zones by lightly touching the affected side.
d. gently palpate the face to compare skin temperature
bilaterally.
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.
Cognitive Level: Application Text Reference: p. 1583
Nursing Process: Assessment NCLEX: Physiological Integrity
3. A patient with trigeminal neuralgia has a glycerol rhizotomy.
During a follow-up visit after the rhizotomy, the nurse will
evaluate that the patient has had a successful outcome for the
surgery if the patient
a. uses an eye shield at night to protect the cornea from injury.
b. develops and implements a daily routine of facial exercises.
c. is careful to chew foods on the unaffected side of the mouth.
d. talks about enjoying social activities with family and friends.
Correct Answer: D
Rationale: Because withdrawal from social activities is a
common manifestation of trigeminal neuralgia, enjoyment of
, social activities indicates successful reduction of symptoms.
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.
Cognitive Level: Application Text Reference: pp. 1583-1584
Nursing Process: Evaluation NCLEX: Physiological Integrity
4. When the nurse is planning care for a hospitalized patient who
is experiencing an acute episode of trigeminal neuralgia, an
appropriate action to include is
a. teach facial and jaw relaxation techniques.
b. assess intake and output and dietary intake.
c. apply ice packs for no more than 20 minutes.
d. spend time at the bedside talking with the patient.
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.
Cognitive Level: Application Text Reference: p. 1583
Nursing Process: Planning NCLEX: Physiological Integrity
System NCLEX Questions With Complete Solutions
6. A patient with Bell's palsy refuses to eat while others are
present because of embarrassment about drooling. The best
response by the nurse to the patient's behavior is to
a. respect the patient's desire and arrange for privacy at
mealtimes.
b. offer the patient liquid nutritional supplements at frequent
intervals.
c. discuss the patient's concerns with visitors who arrive at
mealtimes.
d. teach the patient to chew food on the unaffected side of the
mouth.
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to
encourage adequate nutrition and reduce patient embarrassment.
Liquid supplements will reduce the patient's enjoyment of the
taste of food. It would be inappropriate for the nurse to discuss
the patient's embarrassment with visitors unless the patient
wishes to share this information. Chewing on the unaffected side
of the mouth will enhance nutrition and enjoyment of food but
will not decrease the drooling.
Cognitive Level: Application Text Reference: p. 1585
Nursing Process: Implementation NCLEX: Psychosocial
Integrity
,2. During assessment of the patient with a recurrence of
symptoms of trigeminal neuralgia, the nurse should
a. examine the mouth and teeth thoroughly.
b. have the patient clench and relax the jaw and eyes.
c. identify trigger zones by lightly touching the affected side.
d. gently palpate the face to compare skin temperature
bilaterally.
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.
Cognitive Level: Application Text Reference: p. 1583
Nursing Process: Assessment NCLEX: Physiological Integrity
3. A patient with trigeminal neuralgia has a glycerol rhizotomy.
During a follow-up visit after the rhizotomy, the nurse will
evaluate that the patient has had a successful outcome for the
surgery if the patient
a. uses an eye shield at night to protect the cornea from injury.
b. develops and implements a daily routine of facial exercises.
c. is careful to chew foods on the unaffected side of the mouth.
d. talks about enjoying social activities with family and friends.
Correct Answer: D
Rationale: Because withdrawal from social activities is a
common manifestation of trigeminal neuralgia, enjoyment of
, social activities indicates successful reduction of symptoms.
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.
Cognitive Level: Application Text Reference: pp. 1583-1584
Nursing Process: Evaluation NCLEX: Physiological Integrity
4. When the nurse is planning care for a hospitalized patient who
is experiencing an acute episode of trigeminal neuralgia, an
appropriate action to include is
a. teach facial and jaw relaxation techniques.
b. assess intake and output and dietary intake.
c. apply ice packs for no more than 20 minutes.
d. spend time at the bedside talking with the patient.
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.
Cognitive Level: Application Text Reference: p. 1583
Nursing Process: Planning NCLEX: Physiological Integrity
