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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Using log rolling to reposition the client is not advisable for a client who has increased ICP. Log rolling is a technique that involves moving the client as a unit, without flexing the spine, to prevent spinal cord injury. However, log rolling can also increase ICP by reducing venous drainage from the head and increasing cerebral blood volume. Therefore, the nurse should avoid log rolling the client unless there is a suspected spinal injury.
Choice B reason: Instructing the client to cough and breathe deep is not appropriate for a client who has increased ICP. Coughing and deep breathing can increase intrathoracic pressure, which can reduce venous return to the heart and increase ICP. Additionally, coughing and deep breathing can cause hyperventilation, which can lower the partial pressure of carbon dioxide in the blood and cause cerebral vasoconstriction. This can reduce cerebral perfusion and oxygen delivery to the brain.
Choice C reason: Placing a warming blanket on the client is not recommended for a client who has increased ICP. A warming blanket can increase the body temperature, which can increase the metabolic rate and oxygen demand of the brain. This can worsen cerebral ischemia and edema. Moreover, a warming blanket can cause vasodilation, which can increase cerebral blood volume and ICP. Therefore, the nurse should maintain a normal body temperature for the client and avoid hyperthermia.
Choice D reason: Placing the client in a supine position is the best action for the nurse to take for a client who has increased ICP. The supine position is a way of lying on a table with the back, face, and abdomen facing upwards. It is used for various surgeries and examinations, such as cranial, cardiac, abdominal, and thoracic surgery. It can also prevent respiratory, skin, and circulatory problems. The supine position can help lower ICP by facilitating venous drainage from the head and reducing cerebral blood volume [^10^]. However, the nurse should also elevate the head of the bed to 30 degrees to optimize cerebral perfusion pressure and avoid neck flexion or rotation, which can impair venous drainage.
Correct Answer is C
Explanation
Choice A reason: Performing CPT immediately after the child eats is not a good action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. CPT involves techniques such as percussion, vibration, and postural drainage that help to loosen and remove mucus from the lungs. Performing CPT right after eating can cause nausea, vomiting, or aspiration, especially if the child has gastroesophageal reflux disease (GERD), which is common in cystic fibrosis. The nurse should plan to perform CPT at least 1 hour before or after meals.
Choice B reason: Percussing each lung segment for 15 min is not a necessary action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Percussion is a technique that involves clapping the chest with a cupped hand to create vibrations that loosen the mucus in the airways. Percussion can be done manually or with a mechanical device. The duration of percussion depends on the amount and location of the mucus, but it is usually done for 3 to 5 min per lung segment. Percussing for 15 min per segment can be excessive and cause bruising, pain, or fatigue.
Choice C reason: Administering albuterol prior to CPT is a beneficial action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Albuterol is a bronchodilator that helps to relax the smooth muscles of the airways and improve airflow. Administering albuterol before CPT can enhance the effectiveness of the airway clearance techniques by opening up the airways and making it easier to cough up the mucus.
Choice D reason: Performing vibration during the client’s inspirations is not a correct action for the nurse to plan to take for a child who has cystic fibrosis and a prescription to receive CPT. Vibration is a technique that involves applying pressure and shaking the chest wall during exhalation to help move the mucus out of the lungs. Vibration can be done manually or with a mechanical device. Performing vibration during inspiration can interfere with the inhalation of air and oxygen, and reduce the effectiveness of the technique.
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