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

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Correct Answer is C

Explanation

A) Rubber duck:
A rubber duck may be a suitable toy for a 2-month-old infant during bath time, but it is not considered the most developmentally appropriate for this age. At 2 months, infants are beginning to focus their vision on objects but have limited ability to manipulate toys. Toys such as a rubber duck do not provide the most stimulating developmental experience for an infant at this age.
B) Nesting cups:
Nesting cups are not the most appropriate for a 2-month-old infant. At this stage of development, babies are still in the early stages of hand-eye coordination and grasping skills. Nesting cups are more suitable for older infants (around 6-9 months) who are beginning to explore stacking, nesting, and grasping objects with more precision.
C) Crib mobile:
A crib mobile is an excellent developmentally appropriate toy for a 2-month-old infant. At this age, infants are developing visual tracking skills and are attracted to high-contrast patterns or moving objects. A crib mobile offers visual stimulation and can help an infant focus their eyes on objects, encouraging visual tracking and early sensory development. It is also safe for use in the crib environment.
D) Plastic keys:
Plastic keys can be a good toy for older infants as they begin developing their grasping and mouthing skills, but a 2-month-old infant is not yet able to hold objects or bring them to their mouth with coordination. Toys like these would not offer much benefit in terms of developmental stimulation at this age.

A. Relax your arm across your chest and I will test your elbow extension." B. Place your foot in my hand and I will tap the back of your heel." C. Sit on the edge of the bed while I tap your knee." D. "Lie down and I will stroke the bottom of your foot."

Correct Answer is D

Explanation

A) "Relax your arm across your chest and I will test your elbow extension.": This instruction is not relevant to testing the plantar Babinski reflex. The Babinski reflex involves the lower extremities, specifically the foot, not the arm or elbow. This instruction pertains to testing the upper extremity and is incorrect for this context.

B) "Place your foot in my hand and I will tap the back of your heel.": This is not the correct method for testing the plantar Babinski reflex. The Babinski reflex is tested by stroking the sole of the foot, not by tapping the back of the heel. The test is designed to elicit a response from the foot, not by applying pressure to the heel.

C) "Sit on the edge of the bed while I tap your knee.": This instruction relates to testing the patellar reflex (knee jerk), not the plantar Babinski reflex. The Babinski reflex involves stroking the bottom of the foot, not tapping the knee, so this is not appropriate for the test in question.

D) "Lie down and I will stroke the bottom of your foot.": This is the correct instruction for testing the plantar Babinski reflex. The client should be in a comfortable position, typically lying down, and the nurse should gently stroke the sole of the foot from the heel to the toes to assess the reflex. A normal response in adults is for the toes to curl downward, while an abnormal response (Babinski sign) would be the extension of the big toe and fanning of the other toes.

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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 with a caregiver of a 2-month-old infant about developmentally appropriate toys. which of the following toys should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is preparing to test a client's plantar Babinski reflex. Which of the following instructions should the nurse give to prepare the client for this test?

Correct Answer is D

Explanation

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A client presents to the medical surgical unit.

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