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. Currently prescribed medications are important information, but in this emergent situation, the nurse should first report on the client's condition and immediate concerns.

B. Falling from a ladder as the reason for admission is relevant information, but it does not address the immediate clinical concern of the client's altered mental status.

C. Reporting the increasing confusion of the client is the priority as it highlights the acute change in neurological status, which may indicate a more critical issue such as intracranial injury or neurological impairment.

D. The client's healthcare power of attorney is important for long-term care planning, but it is not the immediate concern when the client presents with altered mental status and potential head
trauma.

A. Leave the client's room so she can act out her anxiety. B. State it is unacceptable to undress during the interview. C. Ignore the client's inappropriate behavior. D. Change to less anxiety-provoking questions.

Correct Answer is B

Explanation

A: Leaving the client alone could increase the risk of harm to herself or others and does not address the immediate need for safety and boundaries.
B: Clearly stating that undressing is unacceptable sets immediate boundaries, which is essential in managing acute behavioral situations, ensuring the client's dignity, and maintaining a professional environment.
C: Ignoring the behavior does not provide any guidance or boundaries for the client, which could lead to escalation or reinforce the inappropriate behavior.
D: While changing to less anxiety-provoking questions may be helpful, it does not directly address the behavior at hand, which could lead to further inappropriate actions or misunderstandings about acceptable behavior during the assessment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first?

Correct Answer is B

Explanation

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