The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately?
Right ear hearing loss.
Difficulty with balance.
Intensifying headache.
Facial numbness.
The Correct Answer is C
A. Right ear hearing loss. While significant, right ear hearing loss is not immediately life- threatening.
B. Difficulty with balance. Balance issues may be concerning but are not typically indicative of a life-threatening condition.
C. Intensifying headache. An intensifying headache can be a sign of increased intracranial pressure, which is a medical emergency and requires immediate attention.
D. Facial numbness. Facial numbness can indicate nerve involvement but is not as immediately concerning as an intensifying headache, which could indicate a serious neurological issue such as bleeding or swelling in the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Self-care deficit relative to motor disturbance. While self-care deficit is a concern for clients with Parkinson's disease due to motor disturbances, the highest priority is addressing the risk for aspiration to prevent potential life-threatening complications such as aspiration pneumonia.
B. Risk for aspiration relative to muscle weakness. Parkinson's disease can cause muscle weakness and impaired swallowing function, leading to an increased risk of aspiration.
Aspiration pneumonia is a severe complication that requires immediate attention, making this the highest priority nursing problem.
C. Risk for constipation relative to immobility. Constipation is a common problem in Parkinson's disease due to immobility and medication side effects. While constipation should be addressed, it is not as immediately life-threatening as the risk for aspiration.
D. Impaired physical mobility relative to muscle rigidity. Impaired physical mobility is a significant concern in Parkinson's disease, but muscle rigidity does not necessarily pose an
immediate risk of aspiration. Addressing impaired mobility is important for maintaining overall function and quality of life but may not be the highest priority in this scenario.
Correct Answer is A
Explanation
A. Do not take any over-the-counter medications. This is crucial because many over-the-counter medications, including those containing acetaminophen, can further damage the liver. Avoiding these medications is essential to prevent further hepatic injury.
B. Eat a high carbohydrate, low fat, low protein diet. While diet can influence liver health, this specific dietary advice is less critical than preventing further liver damage from medications.
C. Call the crisis hot line if feeling lonely. This is important for mental health support, but the immediate physical health concern related to liver damage takes precedence.
D. Avoid exposure to large crowds. This may be relevant if the client is immunocompromised due to liver damage, but it is not as directly related to preventing further liver injury as avoiding certain medications.
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