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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While a history of urinary tract infections is important to know for overall assessment and planning of care, it may not directly affect the decision to insert a urinary catheter unless there are specific concerns related to infection prevention.

B. The client's ability to increase fluid intake may be relevant to their overall hydration status and urinary function but is not directly related to the insertion of an indwelling urinary catheter.

C. This is the most important information to obtain because the nurse needs to ensure that the client does not have any allergies to antiseptic solutions that may be used during the catheter insertion procedure to prevent infection.

D. While the color, clarity, and odor of urine are important indicators of urinary health, they are not the most critical information to obtain prior to catheter insertion. However, assessing urine characteristics is important for ongoing monitoring of urinary function and potential
complications post-insertion.

A. Administer aspirin to prevent further clot formation and platelet clumping. B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. C. Begin continuous observation for transient episodes of neurologic dysfunction. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

Correct Answer is D

Explanation

A. Administer aspirin to prevent further clot formation and platelet clumping. While aspirin may be indicated in the treatment of ischemic stroke, it is not the immediate priority. The client requires further assessment and diagnostic evaluation before initiating specific treatments.
B. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.
Positioning the client is important for maintaining airway patency, but it is not the priority when assessing and managing acute stroke. Immediate interventions to address potential thrombolytic therapy take precedence.
C. Begin continuous observation for transient episodes of neurologic dysfunction. Continuous observation is important for monitoring the client's neurological status, but it is not the first action to take. The client requires urgent diagnostic imaging to confirm the diagnosis and
determine eligibility for thrombolytic therapy.

D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy. This is the priority action. IV access is crucial for administering medications and fluids, and reviewing the inclusion criteria for IV fibrinolytic therapy is essential to determine if the client meets the
criteria for this time-sensitive intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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