Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has rightsided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?
A. Apply an eye patch to the client's right eye.
Applying an eye patch to the client's right eye is not indicated for acoustic neuroma, which is a benign tumor of the vestibulocochlear nerve (cranial nerve VIII). This action would not address the impairment of cranial nerves IX and X, which are responsible for swallowing, gagging, and speech. Therefore, this choice is incorrect.
B. Place suction equipment at the client's bedside.
Placing suction equipment at the client's bedside is a correct action for a nurse to take when caring for a client who has impairment of cranial nerves IX and X. These nerves control the pharyngeal and laryngeal muscles, which are involved in swallowing and preventing aspiration.The client is at risk for choking and aspiration due to impaired gag reflex and difficulty swallowing. Therefore, this choice is correct.
C. Avoid the use of warm water to wash the client's face.
Avoiding the use of warm water to wash the client's face is not necessary for a client who has acoustic neuroma or impairment of cranial nerves IX and X. This action would be more appropriate for a client who has trigeminal neuralgia (cranial nerve V), which causes severefacial pain triggered by stimuli such as heat, cold, or touch. Therefore, this choice is incorrect.
D. Provide rangeofmotion exercises to the client's neck and shoulders.
Providing rangeofmotion exercises to the client's neck and shoulders is not directly related to the care of a client who has acoustic neuroma or impairment of cranial nerves IX and X. This action would be more beneficial for a client who has cervical spondylosis or muscle tension that affects the neck and shoulder mobility. Therefore, this choice is incorrect.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?
A. Cherries
Cherries are not a food that should be eliminated from the diet of a client who is takingselegiline, an MAOI. Cherries do not contain tyramine, which is an amino acid that can cause hypertensive crisis when combined with MAOIs. Therefore, this choice is incorrect.
B. Chicken
Chicken is not a food that should be eliminated from the diet of a client who is takingselegiline, an MAOI. Chicken does not contain tyramine, unless it is aged, smoked, or fermented. Therefore, this choice is incorrect.
C. Cheddar cheese
Cheddar cheese is a food that should be eliminated from the diet of a client who is taking selegiline, an MAOI. Cheddar cheese contains high levels of tyramine, especially if it is aged or processed. Tyramine can interact with MAOIs and cause severe hypertension, headache, nausea, and palpitations. Therefore, this choice is correct.
D. Fresh fish
Fresh fish is not a food that should be eliminated from the diet of a client who is taking selegiline, an MAOI. Fresh fish does not contain tyramine, unless it is pickled, smoked, or fermented. Therefore, this choice is incorrect.
Match the characteristics with the type of stroke. Each characteristic is only used one time.
- Hypertension primary Cause
- Symptoms progress over time
- Rapid progression of symptoms
- Most common type
- Symptoms resolve
- Associated with high risk of stroke
- Atrial fibrillation primary cause
Type of stroke
a.Transient Ischemic Attack b.Hemorrhagic Stroke c.Ischemic Stroke
A. Hypertension primary cause b.,Hemorrhagic Stroke
B. Rapid progression of symptoms
C. Symptoms resolve
D. Associated with high risk of stroke
E. Atrial fibrillation primary cause
A client reports visual disturbances followed by debilitating pain, nausea, and light sensitivity. When providing education for this client, what can the nurse include in teaching?
Select all that apply (Select All that Apply.)
A. Identity and avoid triggers
Correct. Identifying and avoiding triggers can help prevent or reduce the frequency of migraine attacks.
B. Get adequate sleep
Correct. Getting adequate sleep can help maintain a regular circadian rhythm and reduce stress, which are factors that can trigger migraines.
C. Anticipate staying in bed up to 10 days
Incorrect. Staying in bed up to 10 days is not recommended for migraine management, as it can worsen the symptoms and lead to rebound headaches.
D. Identify ways to reduce stress
Correct. Identifying ways to reduce stress can help lower the risk of migraine attacks, as stress is a common trigger for many people.
E. NSAIDs are ineffective