Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.

Diminished hearing

Pupils

Lung assessment

Facial nerve assessment

Vertigo

Pain rating

Answer and Explanation

Correct Answer : D,E,F

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.

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Correct Answer is A

Explanation

A. "I will stop what I am doing and lie down." Stopping activity and resting helps reduce myocardial oxygen demand, which can relieve stable angina. Lying down also minimizes strain on the heart and decreases the risk of injury if the client becomes lightheaded.
B. "I will call the provider after taking one dose of nitroglycerin." Clients with stable angina should take one dose of sublingual nitroglycerin and wait five minutes. If pain persists after three doses taken five minutes apart, emergency medical services should be contacted instead of waiting to call the provider.
C. "I will hold my breath and bear down." The Valsalva maneuver can increase vagal tone, leading to bradycardia and decreased cardiac output, which may worsen angina rather than relieve it. This is not an appropriate response to chest pain.
D. "I will take two 325 milligram aspirin tablets at the same time." While aspirin is beneficial for preventing platelet aggregation, the usual recommended dose for acute chest pain is a single 160–325 mg tablet chewed immediately. Taking two full-dose aspirin tablets is unnecessary and may increase the risk of bleeding.

A. Beneficence B. Justice C. Veracity D. Autonomy

Correct Answer is C

Explanation

A. Beneficence. Beneficence refers to the ethical obligation to promote the well-being of clients and take actions that benefit them. While providing medication education supports the client's health, the primary ethical principle demonstrated in truthfully explaining adverse effects is veracity, not beneficence.
B. Justice. Justice involves fairness in the distribution of resources, treatment, and care. It ensures that all clients receive equitable care regardless of personal or socioeconomic differences. While justice is a fundamental ethical principle, it does not directly relate to truthfulness in medication education.
C. Veracity. Veracity is the ethical principle of honesty and truthfulness in communication with clients. By truthfully informing the client about the adverse effects of their prescribed medications, the nurse upholds veracity, ensuring the client has accurate information for informed decision-making.
D. Autonomy. Autonomy refers to the client’s right to make informed decisions about their care. While providing truthful information supports autonomy, the ethical concept the nurse demonstrates in this scenario is veracity, as the focus is on truthfully sharing medication information.

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Exhibits 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 discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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Exhibits

Which of the following findings requires further action by the nurse?

Select all that apply.