A client presents to the medical surgical unit.
Which of the following findings requires further action by the nurse? Select all that apply.
Pain rating
Lung assessment
Pupils
Facial nerve assessment
Vertigo
Diminished hearing
Correct Answer : D,E
D. Facial nerve assessment: The development of left facial droop and asymmetry postoperatively suggests potential facial nerve (cranial nerve VII) injury during the stapedectomy. This requires immediate evaluation to determine if it is temporary due to surgical manipulation or a sign of nerve damage.
E. Vertigo: Postoperative vertigo and nausea are common but should be monitored closely because stapedectomy involves inner ear structures responsible for balance. Persistent or worsening vertigo may indicate inner ear trauma or perilymphatic fistula, requiring further assessment.
Incorrect:
A. Pain rating: Pain is expected after surgery and can be managed with prescribed analgesics.
B. Lung assessment: Bilateral clear breath sounds do not indicate respiratory distress or complications.
C. Pupils: The slight decrease in pupil size (3.5 mm to 3 mm) is not clinically significant and remains within normal limits.
F. Diminished hearing: Hearing loss is expected post-stapedectomy due to packing in the ear and middle ear healing. Improvement typically occurs over weeks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "The client should use a hair dryer on a warm setting to relieve itching inside the cast.": Using a hair dryer on a warm setting to relieve itching inside the cast is not recommended because it could potentially lead to burns or skin irritation. The client should avoid inserting objects inside the cast to scratch, as this could damage the skin or cause an infection.
B) "The client can shower with the cast after 24 hr.": A plaster cast is not waterproof, and the client should avoid getting it wet. Although the cast may feel dry on the outside after 24 hours, it typically takes about 48 hours or longer for a plaster cast to fully dry and harden. Showering with a plaster cast is not safe, as moisture could cause skin irritation or lead to the development of sores or infection.
C) "The client’s extremity should be elevated after the cast is applied.": Elevating the extremity after a cast is applied is a key teaching point to help reduce swelling and improve circulation. This is especially important during the first 24 to 48 hours after cast application. Elevation helps to prevent or manage swelling, which can be a common complication after an injury and cast application.
D) "The client should keep the cast covered until it is dry.": While it is important to keep a cast clean and dry during the drying process, the cast should not be covered with plastic or other materials that could trap moisture. The cast needs air circulation to dry properly, and covering it could lead to the cast becoming too moist, increasing the risk of skin issues or infection.
Correct Answer is D
Explanation
A) "What makes you believe that the science behind immunization is wrong?": This question may come across as confrontational and judgmental, which can potentially shut down communication. It could make the client feel defensive and less likely to engage in an open discussion about their concerns. The nurse should aim to create a non-judgmental and open dialogue to understand the client's perspective.
B) "Is not taking the immunization worth the risk of getting very sick during flu season?": This question is somewhat leading and may sound as if the nurse is trying to pressure the client into changing their mind. It could also create a sense of guilt or fear rather than fostering a cooperative conversation about the client's beliefs and concerns.
C) "Why are you opposed to receiving immunization?": While this question may seem straightforward, it is a bit too direct and could feel accusatory to the client. It might be better to approach the conversation in a way that invites the client to express their concerns without feeling challenged or defensive.
D) "What is your biggest concern with receiving immunization?": This is the most effective and open-ended question. It allows the client to express their concerns in a non-confrontational way. The nurse can then listen to the client's reasons, provide information, and address any misconceptions or fears the client may have, fostering a respectful and informative discussion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.