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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Eyelid swelling is not a common side effect of sumatriptan. If a patient experiences this side effect, they should report it to their healthcare provider.
Choice B rationale
If the headache persists after taking sumatriptan, the patient can repeat the dose in 1 hour. This is a standard instruction for the use of sumatriptan in the treatment of migraine headaches.
Choice C rationale
Sumatriptan is not typically taken daily to prevent headaches. It is used to treat migraines once they have started.
Choice D rationale
Sumatriptan tablets should be swallowed whole, not chewed. Chewing the tablet could result in too much of the drug being released at once.
Correct Answer is A
Explanation
Choice A rationale
The patient’s blood pressure is significantly low, which could indicate hypotension, a serious side effect of epidural analgesia. This should be the nurse’s priority as it can lead to complications such as decreased perfusion to vital organs.
Choice B rationale
Lower extremity weakness can be a side effect of epidural analgesia, but it is not as immediately life-threatening as hypotension.
Choice C rationale
A slight increase in temperature may not be an immediate concern unless it continues to rise or is accompanied by other signs of infection.
Choice D rationale
Severe itching can be a side effect of epidural analgesia, but it is not as immediately life- threatening as hypotension.
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