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
The correct answer is: a. Development of subcutaneous emphysema
Choice A: Development of subcutaneous emphysema
Reason: Subcutaneous emphysema occurs when air gets trapped under the skin, often due to a leak from the lung or chest tube. This can indicate a serious complication such as a pneumothorax or a malfunctioning chest tube, requiring immediate medical intervention. The presence of subcutaneous emphysema can lead to discomfort, respiratory distress, and further complications if not addressed promptly.
Choice B: Chest tube eyelets not visible
Reason: The eyelets of a chest tube are small holes at the end of the tube that allow air and fluid to drain from the pleural space. These eyelets are typically covered by a dressing and may not be visible. This is not necessarily a cause for concern unless there are other signs of malfunction or complications.
Choice C: Continuous bubbling in the suction control chamber
Reason: Continuous bubbling in the suction control chamber is expected and indicates that the suction is functioning properly. It does not indicate a problem unless the bubbling is in the water seal chamber, which would suggest an air leak.
Choice D: Presence of tidal fluctuation in the water seal chamber
Reason: Tidal fluctuation, or tidaling, in the water seal chamber is a normal finding. It indicates that the chest tube is patent and functioning correctly, as the water level rises with inhalation and falls with exhalation. The absence of tidaling could indicate a blockage or that the lung has fully re-expanded.
Correct Answer is A
Explanation
Choice A reason: This statement indicates that the child understands the role of allergens in triggering asthma symptoms and the importance of avoiding or reducing exposure to them. Allergens such as dust mites, animal dander, mold, and pollen can cause inflammation and constriction of the airways, leading to wheezing, coughing, and shortness of breath. The nurse should teach the child how to identify and eliminate or minimize allergens in the home, school, and outdoor environments.
Choice B reason: This statement is true, but it does not indicate that the child has learned how to manage the condition to prevent asthma attacks. Missing school days is a consequence of poorly controlled asthma, not a cause or a trigger¹². The nurse should teach the child how to use a written asthma action plan, which includes daily medications, peak flow monitoring, and rescue medications, to achieve good asthma control and reduce the risk of exacerbations.
Choice C reason: This statement is false and indicates that the child has a misconception about the impact of asthma on physical activity. Physical activity is beneficial for children with asthma, as it can improve lung function, cardiovascular fitness, and quality of life. The nurse should teach the child how to prevent exercise-induced bronchoconstriction, which is a common trigger of asthma symptoms, by using a short-acting bronchodilator before exercise, warming up and cooling down, and avoiding exercise in cold or polluted air.
Choice D reason: This statement is false and indicates that the child does not recognize the signs of poor asthma control. Coughing and shortness of breath in the morning are common symptoms of nocturnal asthma, which is a sign of uncontrolled asthma and a risk factor for severe asthma attacks. The nurse should teach the child how to monitor and record asthma symptoms and peak flow readings, and how to adjust medications according to the asthma action plan.
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