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 C

Explanation

A. Encourage mobilization to prevent pulmonary embolism.
While mobilization can be important in preventing further DVT development, initial bed rest is often recommended to avoid dislodging the clot. Mobilization should be carefully managed based on the provider's recommendations.

B. Measure each calf's girth to evaluate edema in the affected leg.
Measuring calf girth is useful for monitoring the extent of the DVT, but it is not the most critical intervention compared to monitoring for complications of heparin therapy.

C. Observe for bleeding side effects related to heparin therapy.
This is the correct intervention. Heparin is an anticoagulant, and monitoring for signs of bleeding (such as in the gums, urine, stool, and bruising) is crucial to prevent serious complications.

D. Assess blood pressure and heart rate at least every 4 hours.
While important, frequent monitoring of vital signs is secondary to the need to vigilantly observe for bleeding, which is a direct and significant risk of heparin therapy.

A. Explain that temporary burning at the IV site may occur. B. Apply a topical anesthetic at the infusion site for burning. C. Assess IV site frequently for signs of extravasation. D. Monitor capillary refill distal to the infusion site.

Correct Answer is C

Explanation

A. Explaining that temporary burning at the IV site may occur is important for informing the client about potential side effects but does not address the specific risk associated with vesicant chemotherapeutic agents.

B. Applying a topical anesthetic at the infusion site for burning is not typically indicated during the administration of vesicant chemotherapeutic agents. While it may provide some comfort, it does not address the risk of extravasation.

C. Assessing the IV site frequently for signs of extravasation is essential during the administration of vesicant chemotherapeutic agents. Vesicants can cause tissue necrosis and damage if they leak into surrounding tissues. Early detection of extravasation allows for prompt intervention to minimize tissue damage.

D. Monitoring capillary refill distal to the infusion site is important for assessing peripheral perfusion but does not specifically address the risk of extravasation associated with vesicant chemotherapeutic agents.

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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

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Correct Answer is C

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Correct Answer is C

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