Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.

Diminished hearing

Pupils

Lung assessment

Facial nerve assessment

Vertigo

Pain rating

Answer and Explanation

Correct Answer : D,E,F

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.

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Correct Answer is B

Explanation

A. Completely undress the toddler. Toddlers may feel vulnerable when fully undressed. It is best to remove clothing gradually, assessing one area at a time, to promote comfort and reduce anxiety.
B. Allow the toddler to handle the equipment. Letting the toddler touch and explore medical equipment, such as a stethoscope or otoscope, helps reduce fear and increases cooperation during the examination. This approach fosters a sense of control and familiarity.
C. Thoroughly explain each procedure to the toddler. Toddlers have limited understanding and attention spans. Simple, short explanations and distraction techniques are more effective in easing anxiety than detailed explanations.
D. Start the examination with routine immunizations. Painful procedures, such as vaccinations, should be saved for the end of the visit to prevent distress and resistance that could interfere with the rest of the examination.

A. "I should eat a high-fat diet for several weeks." B. "I should expect to have diarrhea until my diet changes." C. "I should leave my steri-strips on until they fall off." D. "I should expect to have nausea for several days."

Correct Answer is C

Explanation

A. "I should eat a high-fat diet for several weeks." After a laparoscopic cholecystectomy, clients are typically advised to follow a low-fat diet for several weeks to help their bodies adjust to the absence of the gallbladder. The gallbladder stores bile, which aids in the digestion of fats. Without it, a high-fat diet can lead to gastrointestinal discomfort, including cramping and diarrhea. Gradually reintroducing fats based on tolerance is recommended.
B. "I should expect to have diarrhea until my diet changes." While some clients may experience temporary diarrhea after surgery, it is not a universal side effect. Changes in bowel habits can occur due to alterations in bile flow, but not all clients will have diarrhea. Maintaining a balanced diet and gradually increasing fiber intake can help regulate bowel movements and minimize gastrointestinal disturbances.
C. "I should leave my steri-strips on until they fall off." Steri-strips, or adhesive strips used to secure the incision, should be left in place until they naturally fall off, which usually occurs within one to two weeks. Removing them prematurely can compromise the healing process and increase the risk of infection or wound dehiscence.
D. "I should expect to have nausea for several days." Nausea can occur after surgery due to anesthesia, but it should not persist for several days. While some postoperative nausea is normal, ongoing or severe nausea may indicate a complication, such as an adverse reaction to medication or an underlying issue, and should be communicated to the healthcare provider for further evaluation and management.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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Exhibits Complete the following sentence by using the list of options The nurse should first address the client’s dropdownfollowed by the client’sdropdown

Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.