A nurse is caring for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
Place suction equipment at the client’s bedside.
Avoid the use of warm water to wash the client’s face.
Provide range of motion exercises to the client’s neck and shoulders.
Apply an eye patch to the client’s right eye.
The Correct Answer is A
Choice A reason: Placing suction equipment at the client’s bedside is a necessary action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Acoustic neuroma is a noncancerous tumor that develops on the vestibulocochlear nerve, which is responsible for hearing and balance. It can also affect the adjacent cranial nerves, such as the glossopharyngeal (CN IX) and the vagus (CN X) nerves, which are involved in swallowing and gagging. A client with acoustic neuroma may have difficulty swallowing and clearing secretions, which can increase the risk of aspiration and respiratory infections. The nurse should have suction equipment ready to remove any excess saliva or mucus from the client’s mouth or throat.
Choice B reason: Avoiding the use of warm water to wash the client’s face is not a relevant action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. The temperature of the water does not affect the function of these nerves or the tumor. The nurse should use gentle and appropriate hygiene measures to clean the client’s face and prevent skin breakdown.
Choice C reason: Providing range of motion exercises to the client’s neck and shoulders is not a priority action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Range of motion exercises can help to maintain joint mobility and prevent stiffness, but they are not directly related to the cranial nerve impairment or the tumor. The nurse should consult with a physical therapist to determine the best exercise regimen for the client.
Choice D reason: Applying an eye patch to the client’s right eye is not a helpful action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. An eye patch is used to protect the eye from injury or infection, or to treat conditions such as strabismus or amblyopia. An eye patch does not affect the function of the cranial nerves IX and X or the tumor. The nurse should monitor the client’s eye movements and vision, as acoustic neuroma can also affect the facial (CN VII) and oculomotor (CN III) nerves, which are involved in blinking and eye movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygen saturation of the arterial blood. Central cyanosis occurs when the arterial blood has a low oxygen saturation due to a cardiopulmonary problem. The oral mucosa is less affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation.
Choice B reason: The conjunctivae are not a reliable indicator of central cyanosis because they can be affected by other conditions such as anemia, jaundice, or eye infections. The conjunctivae are the thin membranes that cover the white part of the eye and the inner surface of the eyelids.
Choice C reason: The ear lobes are not a reliable indicator of central cyanosis because they can be affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation. The ear lobes are the fleshy lower part of the external ear.
Choice D reason: The soles of the feet are not a reliable indicator of central cyanosis because they can be affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation. The soles of the feet are the bottom part of the feet.
Correct Answer is B
Explanation
Choice A reason: History of hypertension is not a nonmodifiable risk factor for developing a stroke, but a modifiable risk factor. Hypertension is a high blood pressure, defined as 140/90 mm Hg or higher. Hypertension can damage the blood vessels and increase the risk of stroke by causing atherosclerosis, aneurysm, or hemorrhage. The nurse should teach the clients to monitor their blood pressure and take medications as prescribed to lower their blood pressure and reduce their stroke risk.
Choice B reason: Genetics is a nonmodifiable risk factor for developing a stroke. Genetics refers to the inherited traits that are passed down from parents to children. Genetics can influence the risk of stroke by affecting the susceptibility to certain conditions, such as sickle cell disease, clotting disorders, or familial hypercholesterolemia, that can increase the risk of stroke. The nurse should teach the clients to know their family history and discuss their genetic risk factors with their provider.
Choice C reason: Obesity is not a nonmodifiable risk factor for developing a stroke, but a modifiable risk factor. Obesity is a condition of having excess body fat, defined as a body mass index (BMI) of 30 or higher. Obesity can increase the risk of stroke by contributing to other risk factors, such as hypertension, diabetes, or high cholesterol. The nurse should teach the clients to maintain a healthy weight and follow a balanced diet and exercise regimen to lower their stroke risk.
Choice D reason: History of smoking is not a nonmodifiable risk factor for developing a stroke, but a modifiable risk factor. Smoking is the inhalation of tobacco or other substances that contain nicotine or other harmful chemicals. Smoking can increase the risk of stroke by damaging the blood vessels, increasing the blood pressure, reducing the oxygen in the blood, and promoting blood clotting. The nurse should teach the clients to quit smoking and avoid exposure to secondhand smoke to lower their stroke risk.
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