A client presents to the medical surgical unit.

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

Pain rating

Lung assessment

Pupils

Facial nerve assessment

Vertigo

Diminished hearing

Answer and Explanation

Correct Answer : D,E

D. Facial nerve assessment: The development of left facial droop and asymmetry postoperatively suggests potential facial nerve (cranial nerve VII) injury during the stapedectomy. This requires immediate evaluation to determine if it is temporary due to surgical manipulation or a sign of nerve damage.
E. Vertigo: Postoperative vertigo and nausea are common but should be monitored closely because stapedectomy involves inner ear structures responsible for balance. Persistent or worsening vertigo may indicate inner ear trauma or perilymphatic fistula, requiring further assessment.

Incorrect:
A. Pain rating: Pain is expected after surgery and can be managed with prescribed analgesics.
B. Lung assessment: Bilateral clear breath sounds do not indicate respiratory distress or complications.
C. Pupils: The slight decrease in pupil size (3.5 mm to 3 mm) is not clinically significant and remains within normal limits.
F. Diminished hearing: Hearing loss is expected post-stapedectomy due to packing in the ear and middle ear healing. Improvement typically occurs over weeks.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A) "I should position the car seat's retainer clip at the level of my baby's belly button.": This statement is incorrect. The retainer clip of the car seat should be positioned at the level of the baby's armpits, not the belly button. Proper placement of the retainer clip ensures the safety harness fits securely across the baby's chest, reducing the risk of injury during a crash.

B) "I should keep my baby rear-facing in the car seat until she is 2 years old.": This statement is correct and aligns with current guidelines from organizations such as the American Academy of Pediatrics (AAP). Infants and toddlers should remain in a rear-facing car seat until they are at least 2 years old or until they reach the maximum height or weight limit allowed by the car seat manufacturer for rear-facing use. Rear-facing is the safest position for infants and provides the best protection for their developing head, neck, and spine.

C) "I should enable the airbag when my baby is in the front seat of the car.": This statement is incorrect. Infants and young children should never ride in the front seat of a car with an active airbag, as airbags can cause serious injury or death in the event of a collision. Children should always be placed in the back seat, ideally in a rear-facing car seat, to minimize risk.

D) "I should place my baby in the car seat at a 90-degree angle.": This statement is incorrect. A car seat should be installed at a slight recline to ensure that the baby's airway remains open and to prevent their head from falling forward. A 45-degree angle is typically recommended for newborns, although this can vary based on the specific car seat model and the baby's size.

A. A recent move to a new city B. Lack of nutritional knowledge C. Report of feeling depressed D. Recurring urinary tract infections

Correct Answer is A

Explanation

A) A recent move to a new city: A move to a new city is an example of an external stressor. External stressors are environmental or situational factors that create stress, such as life changes, events, or challenges in the outside world. Relocating can involve significant adjustments, such as adapting to a new community, finding housing, and establishing new social connections, all of which can cause stress.

B) Lack of nutritional knowledge: Lack of nutritional knowledge is an internal stressor, as it involves an individual's beliefs, attitudes, and understanding. While it can cause stress, it is a personal factor rather than an external, environmental one.

C) Report of feeling depressed: Feelings of depression are an internal stressor because they are related to an individual’s emotional state or mental health. This reflects the client's internal experience rather than an external environmental factor.

D) Recurring urinary tract infections: Recurring urinary tract infections (UTIs) are a health-related concern and can be seen as a physiological stressor. However, they are not strictly external; they are related to the individual’s health and body rather than external environmental circumstances.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client presents to the medical surgical unit. 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 reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

Correct Answer is A

Explanation

A nurse in an assisted-living facility reinforcing teaching with staff members about preparing for an external chemical disaster. Which of the following instructions should the nurse include?

Select the 2 actions the nurse should prepare to take for the client.

A nurse is reinforcing teaching with a client about advanced directives. Which of the following information should the nurse include?

A nurse is collecting data from a newborn who has fetal alcohol syndrome. Which of the following manifestations should the nurse (Select all that apply.)

A nurse is collecting data for a client who is receiving enteral tube feeding. They should identify that which of the following findings is a manifestation of fluid overload?

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?

A client presents to the medical surgical unit.

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