The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately?

Right ear hearing loss.

Difficulty with balance.

Intensifying headache.

Facial numbness.

Answer and Explanation

The Correct Answer is C

A.   Right ear hearing loss. While significant, right ear hearing loss is not immediately life- threatening.
B.   Difficulty with balance. Balance issues may be concerning but are not typically indicative of a life-threatening condition.
C.   Intensifying headache. An intensifying headache can be a sign of increased intracranial pressure, which is a medical emergency and requires immediate attention.
D.   Facial numbness. Facial numbness can indicate nerve involvement but is not as immediately concerning as an intensifying headache, which could indicate a serious neurological issue such as bleeding or swelling in the brain.

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Correct Answer is A

Explanation

A. Fluid volume deficit. Gastroenteritis, characterized by fever, chills, anorexia, and diarrhea, can lead to significant fluid loss, especially in an older adult who may already have compromised fluid balance due to other factors such as stroke-related immobility. Fluid volume deficit is a critical problem that requires immediate attention to prevent complications such as hypovolemic shock.
B. Bowel incontinence. While bowel incontinence is a concern, it is not as immediately life- threatening as fluid volume deficit.
C. Caregiver role strain. While important for the client's overall well-being, caregiver role strain is a secondary concern compared to the client's physiological needs.
D. Impaired bed mobility. Impaired bed mobility is a long-term issue that requires attention but is not as urgent as addressing the immediate physiological needs of fluid volume deficit.

A. Administer aspirin to prevent further clot formation and platelet clumping. B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. C. Begin continuous observation for transient episodes of neurologic dysfunction. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Correct Answer is D

Explanation

A. Administer aspirin to prevent further clot formation and platelet clumping. While aspirin may be indicated in the treatment of ischemic stroke, it is not the immediate priority. The client requires further assessment and diagnostic evaluation before initiating specific treatments.
B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
Positioning the client is important for maintaining airway patency, but it is not the priority when assessing and managing acute stroke. Immediate interventions to address potential thrombolytic therapy take precedence.
C. Begin continuous observation for transient episodes of neurologic dysfunction. Continuous observation is important for monitoring the client's neurological status, but it is not the first action to take. The client requires urgent diagnostic imaging to confirm the diagnosis and
determine eligibility for thrombolytic therapy.

D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. This is the priority action. IV access is crucial for administering medications and fluids, and reviewing the inclusion criteria for IV fibrinolytic therapy is essential to determine if the client meets the
criteria for this time-sensitive intervention.

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The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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