A nurse is assisting with the care of an adolescent.

Exhibits

Complete the following sentence by using the lists of options.

The adolescent is at risk for developing

dropdown

evidenced by

dropdown

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.

A. Encourage the client to use the overbed trapeze. Using an overbed trapeze helps the client build upper body strength, which is essential for mobility and independence following an amputation. Strengthening the arms and shoulders facilitates bed mobility, transfers, and eventual prosthetic use.
B. Keep a loose, absorbent dressing over the client's surgical site. The surgical site should be covered with a secure, sterile dressing to promote healing and prevent infection. Loose dressings can shift, increasing the risk of contamination and delayed wound healing.
C. Maintain abduction of the client's residual limb with a pillow. Prolonged abduction is not recommended, as it can lead to hip contractures. The limb should be kept in a neutral or slightly extended position to maintain proper alignment and prevent muscle shortening that could interfere with prosthetic use.
D. Caution the client to avoid a prone position while in bed. Prone positioning is actually encouraged intermittently to help stretch the hip flexors and prevent contractures. Avoiding this position may increase the risk of hip flexion contractures, making prosthetic fitting and ambulation more difficult.