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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) "I get nervous when I'm in a large group": This statement indicates social anxiety or discomfort, which is common among adolescents. While it may affect the client's well-being, it does not suggest an immediate risk for suicide.

B) "My partner and I had our first argument last night": While relationship issues can cause stress, this statement by itself does not indicate suicidal ideation. Arguments in relationships are a normal part of adolescent development and are not typically associated with a suicide risk unless other risk factors are present.

C) "I am not interested in anything anymore.": This is a concerning statement, as it suggests anhedonia, a hallmark symptom of depression. A lack of interest in activities once enjoyed, especially in adolescents, can be a significant risk factor for suicide and warrants further evaluation and intervention.

D) "I'm not sleeping much because of all the homework I have.": Although sleep disturbances can be a sign of stress, especially related to academic pressure, this is not an immediate indication of suicidal thoughts. Sleep issues can often be managed with lifestyle changes or stress management techniques.

A. Nutritionist B. Case manager C. Primary care provider D. Pediatric nurse practitioner

Correct Answer is B

Explanation

A) Nutritionist:
While a nutritionist can provide valuable advice on feeding, including breastfeeding or formula feeding, the primary issue here is not related to nutritional guidance but rather the financial concern about paying for baby formula. A nutritionist may provide support, but they are not typically responsible for addressing financial needs or coordinating resources for assistance.

B) Case manager:
The case manager is the most appropriate team member to refer to in this situation. A case manager is responsible for assessing the client’s needs and connecting them with resources such as financial assistance, community support programs, or social services. Since the client is unable to afford baby formula, the case manager can help by referring the client to programs that may provide formula at no cost or at a reduced price, such as the Women, Infants, and Children (WIC) program.

C) Primary care provider:
The primary care provider may offer support and referrals but would generally not be the first point of contact for addressing financial barriers to obtaining baby formula. The primary care provider can provide medical advice related to the client's postpartum care and the infant's health, but they are not typically the best person to address financial concerns directly.

D) Pediatric nurse practitioner:
A pediatric nurse practitioner focuses on providing care for the child, not necessarily addressing the financial needs of the family. While they can provide guidance on infant care and feeding, the issue of financial support for formula is outside their role. The case manager would be the more appropriate referral to assist with financial concerns.

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A client presents to the medical surgical unit. Which of the following findings requires further action by the nurse? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an adolescent during an annual physical examination. Which of the following statements by the client indicates that they are at risk for suicide?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A client presents to the medical surgical unit.

Which of the following findings requires further action by the nurse? Select all that apply.