A nurse is caring for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
Place suction equipment at the client’s bedside.
Avoid the use of warm water to wash the client’s face.
Provide range of motion exercises to the client’s neck and shoulders.
Apply an eye patch to the client’s right eye.
The Correct Answer is A
Choice A reason: Placing suction equipment at the client’s bedside is a necessary action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Acoustic neuroma is a noncancerous tumor that develops on the vestibulocochlear nerve, which is responsible for hearing and balance. It can also affect the adjacent cranial nerves, such as the glossopharyngeal (CN IX) and the vagus (CN X) nerves, which are involved in swallowing and gagging. A client with acoustic neuroma may have difficulty swallowing and clearing secretions, which can increase the risk of aspiration and respiratory infections. The nurse should have suction equipment ready to remove any excess saliva or mucus from the client’s mouth or throat.
Choice B reason: Avoiding the use of warm water to wash the client’s face is not a relevant action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. The temperature of the water does not affect the function of these nerves or the tumor. The nurse should use gentle and appropriate hygiene measures to clean the client’s face and prevent skin breakdown.
Choice C reason: Providing range of motion exercises to the client’s neck and shoulders is not a priority action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Range of motion exercises can help to maintain joint mobility and prevent stiffness, but they are not directly related to the cranial nerve impairment or the tumor. The nurse should consult with a physical therapist to determine the best exercise regimen for the client.
Choice D reason: Applying an eye patch to the client’s right eye is not a helpful action for the nurse to take for a client who has right sided acoustic neuroma resulting in impairment of cranial nerves IX and X. An eye patch is used to protect the eye from injury or infection, or to treat conditions such as strabismus or amblyopia. An eye patch does not affect the function of the cranial nerves IX and X or the tumor. The nurse should monitor the client’s eye movements and vision, as acoustic neuroma can also affect the facial (CN VII) and oculomotor (CN III) nerves, which are involved in blinking and eye movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Ask the client to read a Snellen chart. This method is used to assess cranial nerve II, which is the optic nerve. The optic nerve is responsible for vision and visual acuity. A Snellen chart is a tool that displays letters of different sizes and measures how well the client can see them from a distance of 20 feet.
Choice B reason: Ask the client to clench his teeth. This method is not used to assess cranial nerve II, but cranial nerve V, which is the trigeminal nerve. The trigeminal nerve is responsible for sensation and motor function of the face, mouth, and jaw. Clenching the teeth tests the strength and symmetry of the masseter and temporalis muscles, which are innervated by the trigeminal nerve.
Choice C reason: Listen to the client’s speech. This method is not used to assess cranial nerve II, but cranial nerves IX, X, and XII, which are the glossopharyngeal, vagus, and hypoglossal nerves. These nerves are responsible for speech production and swallowing. Listening to the client’s speech tests the quality, clarity, and articulation of the voice, as well as the movement and coordination of the tongue and palate.
Choice D reason: Ask the client to identify scented aromas. This method is not used to assess cranial nerve II, but cranial nerve I, which is the olfactory nerve. The olfactory nerve is responsible for smell and olfaction. Asking the client to identify scented aromas tests the ability to detect and recognize different odors.
Correct Answer is C
Explanation
Choice A reason: Difficulty moving the upper extremities is not a complication of immobility, but a result of the stroke. A stroke can damage the part of the brain that controls movement, sensation, or coordination of the limbs, causing hemiparesis (weakness) or hemiplegia (paralysis) on one side of the body. The nurse should assist the client with passive or active range of motion exercises to prevent muscle atrophy and contractures.
Choice B reason: Stiffness in the lower extremities is not a complication of immobility, but a result of the stroke. A stroke can affect the muscle tone of the limbs, causing spasticity (increased muscle tension) or flaccidity (decreased muscle tone) on one side of the body. The nurse should apply splints or braces to prevent deformities and provide massage or stretching to relieve stiffness.
Choice C reason: A reddened area over the sacrum is a complication of immobility, and a sign of a pressure injury. A pressure injury is a localized damage to the skin and underlying tissue caused by prolonged pressure, friction, or shear. The sacrum is a common site for pressure injuries, as it is a bony prominence that bears the weight of the body when lying down. The nurse should reposition the client every 12 hours, provide skin care, and use pressure relieving devices to prevent pressure injuries.
Choice D reason: Difficulty hearing some types of sounds is not a complication of immobility, but a result of aging or other factors. Hearing loss can occur due to various causes, such as exposure to loud noise, ear infections, earwax buildup, or ototoxic medications. The nurse should assess the client's hearing and use communication strategies, such as speaking clearly, facing the client, and reducing background noise.
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