The nurse is assessing a patient with a cochlear implant and notices that there is drainage, swelling, and tenderness behind the ear with the implant. What is the priority nursing intervention?
Anticipate a medical prescription for a hearing test
Obtain a culture of the drainage
Remove any foreign body from the ear canal
Obtain a medical prescription for a CT of the skull
The Correct Answer is B
A. A hearing test does not address the infection symptoms and would not be the priority.
B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.
C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.
D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.
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Related Questions
Correct Answer is C
Explanation
A. While lung injury could occur in traumatic situations, it is not the primary reason for mechanical ventilation in the context of a spinal cord injury.
B. A history of smoking may affect lung health but does not directly justify the immediate need for mechanical ventilation following a spinal cord injury.
C. The nerves that control lung function may be injured in a cervical spinal cord injury, particularly at higher levels like C3-C5, leading to respiratory muscle paralysis and necessitating mechanical ventilation to support breathing.
D. While unconsciousness may complicate breathing, the primary concern is the loss of function in the spinal cord nerves controlling respiration.
Correct Answer is A
Explanation
A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.
B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.
C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.
D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.
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