A nurse is caring for a patient who has a right-sided acoustic neuroma, resulting in impairment of cranial nerves IX and
X. Which of the following interventions should the nurse implement?
Avoid using warm water to wash the patient’s face.
Apply an eye patch to the patient’s right eye.
Provide range-of-motion exercises to the patient’s neck and shoulders.
Place suction equipment at the patient’s bedside.
The Correct Answer is D
Choice A rationale
Avoiding warm water to wash the patient’s face is not typically necessary for a patient with a right-sided acoustic neuroma.
Choice B rationale
Applying an eye patch to the patient’s right eye is not typically necessary unless the patient is experiencing double vision, which is not a common symptom of acoustic neuroma.
Choice C rationale
Providing range-of-motion exercises to the patient’s neck and shoulders is not typically necessary for a patient with a right-sided acoustic neuroma.
Choice D rationale
Placing suction equipment at the patient’s bedside can be helpful if the patient is experiencing difficulty swallowing or has a risk of aspiration due to impairment of cranial nerves IX and X111213.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale
Performing passive range of motion exercises on the right leg in Buck’s traction may not be appropriate. These exercises involve moving the joint without the patient’s muscles doing the work, which could disrupt the traction.
Choice B rationale
Isometric exercises involve contracting the muscles without moving the joints. While these exercises can be beneficial for maintaining muscle strength, they may not promote mobility.
Choice C rationale
Performing active range-of-motion exercises on the left leg can help promote mobility. These exercises involve the patient moving the joint through its full range of motion, which can help maintain joint flexibility and muscle strength.
Choice D rationale
Log rolling the patient every 2 hours may not be appropriate for a patient in Buck’s traction. This technique involves turning the patient as a unit to prevent twisting and protect the spine, which could disrupt the traction.
Correct Answer is A
Explanation
Choice A rationale
Frothy sputum is a common finding in patients with left-sided heart failure. This is due to fluid accumulation in the lungs (pulmonary edema), which can cause the sputum to become frothy.
Choice B rationale
Dependent edema is more commonly associated with right-sided heart failure. It occurs due to fluid accumulation in the systemic circulation, leading to swelling in the lower extremities.
Choice C rationale
Nocturnal polyuria can occur in heart failure, but it is not a specific sign of left-sided heart failure.
Choice D rationale
Jugular venous distention is a sign of right-sided heart failure, not left-sided heart failure. It occurs due to increased pressure in the right atrium, leading to visible distention of the jugular veins.
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