A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?

Lie on your back when sleeping.

Lie on your front when sleeping.

Resume your exercise routine.

Wash your hair 24 hr after surgery.

Answer and Explanation

The Correct Answer is D

A. Lie on your back when sleeping: Lying on the back when sleeping may be recommended initially after cochlear implant surgery to avoid putting pressure on the surgical site. However, this instruction should not be included in the plan of care indefinitely. Once the client is comfortable and the surgical site is healing well, they should be allowed to sleep in any position that is comfortable for them.

B. Lie on your front when sleeping: Lying on the front when sleeping is not typically recommended after cochlear implant surgery, as it may put pressure on the surgical site and disrupt healing. This position could potentially cause discomfort and increase the risk of complications. Therefore, this instruction should not be included in the plan of care.

C. Resume your exercise routine: Resuming the exercise routine immediately after cochlear implant surgery may not be advisable. The client should be instructed to avoid strenuous activities and heavy lifting for a certain period as advised by the healthcare provider. Engaging in vigorous exercise too soon after surgery could potentially disrupt the healing process and increase the risk of complications. Therefore, this instruction should not be included in the plan of care immediately after surgery.

D. Wash your hair 24 hr after surgery: After cochlear implant insertion, it is important to keep the surgical site clean to prevent infection. Washing the hair 24 hours after surgery helps to maintain cleanliness and hygiene without disrupting the surgical site. It is typically safe to wash the hair after this period as long as gentle care is taken to avoid excessive manipulation of the implant site.

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Correct Answer is A

Explanation

A. A decrease in systolic blood pressure greater than 10 mm Hg during inspiration: Pulsus paradoxus is an exaggerated decrease in systolic blood pressure during inspiration. Normally, there is a slight decrease in systolic blood pressure during inspiration due to increased intrathoracic pressure and decreased venous return to the heart. However, in conditions such as cardiac tamponade or severe asthma exacerbations, the decrease in systolic blood pressure during inspiration is more pronounced (>10 mm Hg), indicating impaired cardiac output and decreased left ventricular filling during inspiration.

B. A decrease in heart rate greater than 10/min when lying down: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus primarily refers to changes in systolic blood pressure during inspiration rather than alterations in heart rate when lying down.

C. An increase in diastolic blood pressure greater than 10 mm Hg during inspiration: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus is characterized by an exaggerated decrease in systolic blood pressure during inspiration, not changes in diastolic blood pressure.

D. An increase in heart rate greater than 20/min when standing: This finding is not indicative of pulsus paradoxus. Pulsus paradoxus primarily refers to changes in systolic blood pressure during inspiration rather than alterations in heart rate when standing.

A. Leave the client alone while ensuring safety, to allow the client to work through behaviors and feelings during the transition period. B. Provide opportunities for education and continually evaluate the client's preferences and goals for care. C. Limit the members of the team who can help the client while transitioning, to avoid adding confusion or uneasiness. D. Inform the client about the need to move prior to the actual event.

Correct Answer is B

Explanation

B. Provide opportunities for education and continually evaluate the client's preferences and goals for care:
This is the most effective intervention. Providing education and involving the client (to the extent possible) in decision-making helps reduce anxiety and build trust. Even though individuals with Alzheimer's disease may have limited memory and cognitive abilities, ongoing communication about the transition and individualized care plans can help ease the process. Additionally, continuously evaluating the client's preferences and goals ensures that the care plan remains person-centered and aligns with their needs, helping to minimize relocation stress.

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A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?

Nursing Test Bank

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