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.

A.Emptying the ostomy pouch before removing the skin barrier reduces the risk of spillage and makes the procedure less messy. It is also more comfortable for the client and helps prevent leakage of stool onto the skin, which can cause irritation.

B. It’s generally recommended to change an ostomy appliance when the bowel is least active, such as before meals or several hours after eating. Changing it one hour after breakfast may coincide with increased bowel activity, which can increase the risk of leakage and make the change more challenging.

C.Moisturizing soaps should be avoided when cleaning the skin around the stoma because they can leave a residue that interferes with the adhesion of the skin barrier, potentially leading to leakage. The nurse should use a mild, non-moisturizing soap or just water to clean the area to ensure proper adhesion of the appliance.

D.The opening on the skin barrier should closely match the size of the stoma, with a slight gap of about 1/8 inch (0.3 cm) around it to avoid pressure on the stoma while also protecting the surrounding skin. Creating an opening that is 0.5 inches (1.27 cm) larger than the stoma would leave too much skin exposed, increasing the risk of irritation and infection.

A. Understands that everyone dies eventually: Preschoolers typically do not have a concrete understanding of the concept of death or the inevitability of death for everyone. Their understanding is usually very limited and concrete, so this would not be consistent with their developmental stage.

B. Recognizes the parent will never wake up: Preschoolers may have difficulty understanding the permanence of death. They might think that the deceased parent will wake up eventually or return, as their grasp on the concept of permanence is not fully developed.

C. Expresses curiosity about the funeral service: While preschoolers may be curious about many things, including new experiences, their understanding of a funeral and its significance may be limited. They might not fully grasp the meaning behind the service but may ask questions out of curiosity.

D. Believes death is punishment for bad behavior: Preschoolers often think in magical or egocentric ways and may believe that death is a punishment for something they or others did wrong. This belief reflects their developmental stage, where they may not understand the abstract concept of death and may interpret it in relation to their own actions or behaviors.