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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Lifting a patient under the shoulders by two nurses can be strenuous and may not provide adequate support for a patient who can only partially assist.
Choice B rationale
While this method may work for some patients, it relies heavily on the patient’s strength and ability to push with their feet. If the patient is weak or unable to exert enough force, this method could be unsafe.
Choice C rationale
Using a device to reduce friction is the most appropriate technique when shifting a patient who can only partially assist. Devices such as slide sheets or transfer boards can help move the patient smoothly and with less physical strain on the healthcare provider.
Choice D rationale
Lifting the patient’s legs while the patient uses a trapeze bar requires significant upper body strength from the patient and may not be feasible for all patients.
Correct Answer is B
Explanation
Choice A rationale
The glomerular filtration rate (GFR) does not recover during the oliguric phase of acute kidney injury (AKI). Recovery of GFR typically occurs during the recovery phase.
Choice B rationale
During the oliguric phase of AKI, urine output is typically less than 400 mL per 24 hours.
Choice C rationale
Renal function is not reestablished during the oliguric phase of AKI. This typically occurs during the recovery phase.
Choice D rationale
Blood urea nitrogen (BUN) and creatinine levels do not decrease during the oliguric phase of AKI. These levels typically increase due to decreased kidney function.
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