Which of the following are priority nursing assessments related to a client post-op transsphenoidal hypophysectomy for a tumor of the pituitary g (Select All that Apply.)
Monitor for increased intracranial pressure
Monitor incision under the top lip for infection
Assess for signs of deep vein thrombosis (DVT)
Development of meningitis
Assess for signs of cerebrospinal fluid (CSF) leak
Correct Answer : A,B,D,E
A. Monitor for increased intracranial pressure is correct. Following a transsphenoidal hypophysectomy, it is essential to monitor for signs of increased intracranial pressure (ICP) due to the proximity of the surgery to the brain and the risk of complications such as bleeding, swelling, or fluid buildup. Symptoms of increased ICP include headache, nausea, vomiting, and altered level of consciousness.
B. Monitor incision under the top lip for infection is correct. The incision for a transsphenoidal hypophysectomy is typically made under the top lip or at the base of the nose, and it is essential to monitor this site for signs of infection, such as redness, swelling, drainage, or increased pain.
C. Assess for signs of deep vein thrombosis (DVT) is incorrect. Although DVT prevention (e.g., ambulation, use of compression stockings) is important after surgery, monitoring for DVT is not a priority assessment specifically related to a transsphenoidal hypophysectomy. The other assessments are more directly related to potential complications from this specific type of surgery.
D. Development of meningitis is correct. Meningitis is a potential complication after a transsphenoidal hypophysectomy, especially if there is a breach in the nasal cavity or sinus, allowing for infection to spread. Signs of meningitis include fever, nausea, stiff neck, and headache.
E. Assess for signs of cerebrospinal fluid (CSF) leak is correct. A CSF leak is a serious complication of transsphenoidal surgery, as it can occur if the dura is punctured during the procedure. This leads to leakage of cerebrospinal fluid, which may manifest as a clear, watery drainage from the nose, a condition that should be assessed for immediately to prevent further complications like infection.
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Related Questions
Correct Answer is A
Explanation
A. Transactional theory is correct. Transactional leadership focuses on the use of rewards and punishments to motivate followers. In this scenario, the head nurse tracks the performance of nurses and rewards the top performers with monetary incentives or time off. This aligns with transactional leadership, where the focus is on maintaining performance standards and rewarding or punishing based on results.
B. Situational theory is incorrect. Situational leadership theory suggests that leadership styles should change depending on the situation or the maturity of the followers. The example provided doesn't demonstrate a flexible or adaptive leadership approach, so this theory doesn't apply.
C. Behavior theory is incorrect. Behavioral leadership theory focuses on the behaviors and actions of leaders, such as consideration (caring about employees) and initiating structure (setting goals and expectations). While some elements of this theory could be seen in the example, the emphasis on rewards and performance tracking fits better with transactional leadership.
D. Transitional theory is incorrect. It seems you may be referring to transformational leadership, which involves inspiring and motivating followers to achieve higher levels of performance and personal growth. This is not the case here, as the focus in this example is on rewards for meeting specific performance goals, which is more aligned with transactional leadership.
Correct Answer is B
Explanation
A. Require staff nurses to demonstrate competency by passing a medication administration examination is incorrect. While testing competency may be part of the solution later, it is not the first step. The CQI process should begin by understanding why errors occurred, not by immediately requiring examinations without understanding the root causes.
B. Review the events leading up to each medication administration error is correct. The first step in a Continuous Quality Improvement (CQI) program should be to gather data and analyze the root causes of the medication errors. By reviewing the events that led to the errors, the committee can identify systemic problems, whether related to processes, communication, or individual actions. This approach helps to focus the improvement efforts on addressing the actual causes of the errors rather than just treating the symptoms.
C. Develop a quality improvement program for nurses involved in medication administration errors is incorrect. Developing a quality improvement program is an important step, but the first step in CQI is to gather and analyze data to identify why errors are occurring. The program should be based on findings from the error reviews.
D. Provide an in-service on medication administration to all the nurses is incorrect. While education and in-service training are useful for improving practice, the first step in CQI is to identify the problem. The committee needs to understand the reasons behind the medication errors before implementing training programs.
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