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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Encourage brief exercise before meals to promote appetite. This answer is incorrect because exercise before meals can increase fatigue and decrease appetite in some clients with dysphagia. Exercise can also affect the blood flow to the brain and the muscles involved in swallowing .

Choice B reason: Encourage the client to take small bites. This answer is correct because taking small bites can help the client swallow more easily and reduce the risk of choking or aspiration.

Choice C reason: Place the client with the head reclined back to facilitate swallowing. This answer is incorrect because placing the client with the head reclined back can impair the swallowing mechanism and increase the risk of aspiration. The client should be placed with the head tilted slightly forward to help the food move down the throat.

Choice D reason: Place food in the affected side of the mouth. This answer is incorrect because placing food in the affected side of the mouth can cause the food to remain in the mouth and not be swallowed properly. The client should be encouraged to use both sides of the mouth to chew and swallow food.

A. Hyperthermia B. Absence of bowel sounds C. Polyuria D. Weakened gag reflex E. Hypotension

Correct Answer is ["B","D","E"]

Explanation

Choice A reason: Hyperthermia. This answer is incorrect because hyperthermia is not a complication of a cervical spinal cord injury, but rather a condition that can worsen the injury. Hyperthermia can increase the metabolic demand and oxygen consumption of the injured spinal cord, leading to more damage and inflammation.

Choice B reason: Absence of bowel sounds. This answer is correct because absence of bowel sounds is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the gastrointestinal system. A cervical spinal cord injury can cause spinal shock, which leads to decreased peristalsis and paralytic ileus.

Choice C reason: Polyuria. This answer is incorrect because polyuria is not a complication of a cervical spinal cord injury, but rather a condition that can occur after the resolution of spinal shock. Polyuria can result from the loss of sympathetic control over the renal system, leading to increased urine output and decreased antidiuretic hormone secretion.

Choice D reason: Weakened gag reflex. This answer is correct because weakened gag reflex is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the respiratory system. A cervical spinal cord injury can cause damage to the cranial nerves that control the gag reflex, leading to difficulty swallowing, aspiration, and pneumonia.

Choice E reason: Hypotension. This answer is correct because hypotension is a complication of a cervical spinal cord injury, which can affect the autonomic nervous system and impair the function of the cardiovascular system. A cervical spinal cord injury can cause neurogenic shock, which leads to decreased sympathetic tone, vasodilation, and reduced cardiac output.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is instructing a client’s family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is teaching a client who has tuberculosis and is to start medication therapy with isoniazid, rifampin and pyrazinamide. Which of the following instructions should the nurse include?

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client’s partner should indicate to the nurse that the teaching was effective?

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator associated pneumonia?

A nurse is evaluating teaching on a client who has a new prescription for montelukast to treat asthma. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS) and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

A nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is caring for a client who has a disposable three chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?