Nurses' Notes Preoperative 0730:

The client is scheduled for a left stapedectomy.

Pupils 3.5 mm, equal, round, and reactive to light. Smile symmetrical.

Mucous membranes show color expected for the client's skin tone and moisture.

Speech clear.

Skin warm and dry. Lungs clear bilaterally.

Apical heart rate regular at 78/min. Postoperative

1230:

Pupils were 3 mm, equal, and reactive to light.

Smile asymmetrical. Mucous membranes pink. Speech hoarse.

Client with left facial droop Skin warm and dry.

The client reports vertigo and nausea.

Bilateral breath sounds clear and present throughout. Apical heart rate regular at 92/min.

The client reports left ear discomfort and rates the pain as 5 on a scale of 0 to 10. The client states that her hearing has diminished following surgery.

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

Creating a schedule of daily tasks can help provide structure and routine for individuals with Alzheimer's disease. Having a predictable routine can reduce confusion and frustration by providing a sense of familiarity and stability. The schedule should include activities that the client enjoys and can manage within their abilities. It can help the client feel more organized and engaged throughout the day.

Limiting the use of familiar objects is not recommended. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease. They can help trigger memories and create a sense of familiarity in their environment. Removing familiar objects may increase disorientation and frustration.

Asking questions that require more than one answer can be overwhelming for individuals with Alzheimer's disease. Complex questions can lead to confusion and frustration as the person may struggle to recall or process information. It is best to ask simple and direct questions that can be easily understood and answered.

Having several family members visit daily may cause additional stress and confusion for the client with Alzheimer's disease. Too many visitors can be overwhelming and may disrupt the person's routine or environment. It is important to consider the individual's preferences and abilities when planning visits and ensure that they are manageable and supportive for the client's well-being.

The correct answer is choice b. “I will stop what I am doing and lie down.”

Choice A rationale:

Taking two 325 milligram aspirin tablets at the same time is not the recommended immediate action for chest pain. Aspirin can help in preventing blood clots, but it is not the first step in managing acute angina.

Choice B rationale:

Stopping activity and lying down is the correct initial response to chest pain. This helps reduce the heart’s workload and can alleviate the pain.

Choice C rationale:

Calling the provider after taking one dose of nitroglycerin is important, but it is not the first step. The client should first stop activity and lie down, then take nitroglycerin if prescribed.

Choice D rationale:

Holding the breath and bearing down (Valsalva maneuver) is not appropriate for managing chest pain and can actually increase the heart’s workload, potentially worsening the situation.