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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Every 5 minutes for 30 minutes is crucial after paracentesis to closely monitor for signs of hypovolemia, such as a sudden drop in blood pressure. After this initial intensive monitoring period, the frequency can be reduced to every 4 hours to assess for any delayed effects or complications.
B. Every 5 minutes for one hour is a shorter duration of monitoring compared to option A and
may not provide adequate time to detect and respond to any significant changes in blood pressure that could occur after paracentesis, especially considering the volume of fluid removed.
C. Every 15 minutes for one hour, then every 1 hour for 2 hours provides frequent monitoring
initially, but the interval between assessments is too long after the first hour, potentially missing early signs of complications such as hypovolemia.
D. Every 1 hour for 2 hours does not provide sufficient frequency of monitoring, especially during the critical immediate post-paracentesis period when rapid changes in blood pressure can occur. This schedule may delay the detection and management of complications.
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