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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is: a. Development of subcutaneous emphysema

Choice A: Development of subcutaneous emphysema

Reason: Subcutaneous emphysema occurs when air gets trapped under the skin, often due to a leak from the lung or chest tube. This can indicate a serious complication such as a pneumothorax or a malfunctioning chest tube, requiring immediate medical intervention. The presence of subcutaneous emphysema can lead to discomfort, respiratory distress, and further complications if not addressed promptly.

Choice B: Chest tube eyelets not visible

Reason: The eyelets of a chest tube are small holes at the end of the tube that allow air and fluid to drain from the pleural space. These eyelets are typically covered by a dressing and may not be visible. This is not necessarily a cause for concern unless there are other signs of malfunction or complications.

Choice C: Continuous bubbling in the suction control chamber

Reason: Continuous bubbling in the suction control chamber is expected and indicates that the suction is functioning properly. It does not indicate a problem unless the bubbling is in the water seal chamber, which would suggest an air leak.

Choice D: Presence of tidal fluctuation in the water seal chamber

Reason: Tidal fluctuation, or tidaling, in the water seal chamber is a normal finding. It indicates that the chest tube is patent and functioning correctly, as the water level rises with inhalation and falls with exhalation. The absence of tidaling could indicate a blockage or that the lung has fully re-expanded.

A. Blood glucose levels B. Thyroid function studies C. Gallbladder studies D. Liver function tests

Correct Answer is D

Explanation

Choice A reason: Blood glucose levels are not a necessary laboratory test for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Blood glucose levels measure the amount of sugar in the blood and are used to diagnose and monitor diabetes. Rifampin and pyrazinamide do not affect blood glucose levels directly, but they may interact with some medications used to treat diabetes, such as sulfonylureas or metformin. The nurse should advise the client to monitor their blood glucose levels regularly and report any changes to the provider.

Choice B reason: Thyroid function studies are not a required laboratory test for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Thyroid function studies measure the levels of thyroid hormones and thyroid stimulating hormone in the blood and are used to diagnose and monitor thyroid disorders. Rifampin and pyrazinamide do not affect thyroid function directly, but they may interact with some medications used to treat thyroid disorders, such as levothyroxine or propylthiouracil. The nurse should advise the client to take their thyroid medication at least 4 hours before or after rifampin and pyrazinamide and report any symptoms of thyroid imbalance to the provider.

Choice C reason: Gallbladder studies are not a relevant laboratory test for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Gallbladder studies include ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI) scans of the gallbladder and are used to diagnose and monitor gallstones or gallbladder inflammation. Rifampin and pyrazinamide do not affect the gallbladder directly, but they may cause side effects such as nausea, vomiting, or abdominal pain, which can mimic gallbladder problems. The nurse should assess the client for signs of hepatotoxicity, such as jaundice, dark urine, or clay colored stools, and report any findings to the provider.

Choice D reason: Liver function tests are a vital laboratory test for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Liver function tests measure the levels of enzymes, proteins, and bilirubin in the blood and are used to diagnose and monitor liver damage or disease. Rifampin and pyrazinamide are both hepatotoxic drugs, which means they can cause liver injury or failure. The nurse should instruct the client to have liver function tests done before starting the medication regimen and periodically during the treatment. The nurse should also educate the client about the signs and symptoms of hepatotoxicity, such as fatigue, loss of appetite, nausea, vomiting, or yellowing of the skin or eyes, and advise them to stop taking the medication and seek medical attention if they occur.

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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?

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