A nurse is caring for a patient who has a right-sided acoustic neuroma, resulting in impairment of cranial nerves IX and
X. Which of the following interventions should the nurse implement?
Avoid using warm water to wash the patient’s face.
Apply an eye patch to the patient’s right eye.
Provide range-of-motion exercises to the patient’s neck and shoulders.
Place suction equipment at the patient’s bedside.
The Correct Answer is D
Choice A rationale
Avoiding warm water to wash the patient’s face is not typically necessary for a patient with a right-sided acoustic neuroma.
Choice B rationale
Applying an eye patch to the patient’s right eye is not typically necessary unless the patient is experiencing double vision, which is not a common symptom of acoustic neuroma.
Choice C rationale
Providing range-of-motion exercises to the patient’s neck and shoulders is not typically necessary for a patient with a right-sided acoustic neuroma.
Choice D rationale
Placing suction equipment at the patient’s bedside can be helpful if the patient is experiencing difficulty swallowing or has a risk of aspiration due to impairment of cranial nerves IX and X111213.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The patient has the right to withdraw their informed consent at any time, even after signing the consent form. This is a fundamental principle of patient autonomy and respect for the individual’s rights. The nurse should respect the patient’s decision and notify the surgeon that the patient wishes to withdraw informed consent for the procedure. This allows the healthcare team to reassess the situation, provide further information if necessary, and make appropriate adjustments to the care plan.
Choice B rationale
While informing the surgical team to cancel the surgery might be a subsequent step, it is not the immediate action the nurse should take. The first action should be to respect the patient’s autonomy and communicate their decision to the surgeon.
Choice C rationale
Proceeding with the preparation of the patient for the surgical procedure against their expressed wishes would be a violation of the patient’s rights. It is essential to respect the patient’s autonomy and their right to make decisions about their own healthcare.
Choice D rationale
Reminding the patient that a signed informed consent form is a legally binding document is incorrect. Informed consent is not a contract, and the patient has the right to withdraw consent at any time. The purpose of informed consent is to ensure that the patient understands the procedure, its risks and benefits, and alternatives, and makes an informed decision.
Correct Answer is C
Explanation
Choice A rationale
Telling the patient that this is the medication their doctor wants them to take does not address the patient’s concern about the color of the pill.
Choice B rationale
While it’s true that the same medication can sometimes come in different colors, this response does not confirm that the orange pill is the correct medication for the patient.
Choice C rationale
Checking the medication order again is the best response. This will ensure that the patient is receiving the correct medication.
Choice D rationale
Explaining the purpose of the medication does not address the patient’s concern about the color of the pill.
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