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 B

Explanation

A. Neck pain can occur in some patients following electroconvulsive therapy (ECT) due to muscle tension or positioning during the procedure. However, it is not a common or expected adverse reaction associated with ECT, so it is not the primary concern to address.
B. Temporary memory loss is a well-documented adverse reaction following ECT. Patients may experience difficulties with short-term memory, particularly related to events that occurred around the time of the treatment. This memory loss is usually temporary, but it can be distressing for some individuals.
C. Voice alteration is not typically associated with ECT. Although some patients may experience hoarseness or changes in vocal quality due to intubation or anesthesia, this is not a direct result of ECT itself and is not commonly mentioned in the context of ECT side effects.
D. Tingling of the scalp is not a recognized adverse reaction to ECT. Patients may experience various sensations, but tingling is not a common or documented response. The primary focus should be on more significant effects, such as temporary memory loss and potential confusion immediately following the treatment.

Correct Answer is ["0.25"]

Explanation

Volume = Desired Dose / Available Concentration

Desired: 0.5 mg

Available: 2 mg/mL

Calculation:

Volume = 0.5 mg / 2 mg/mL

Volume = 0.25 mL

Answer: 0.25 mL

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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 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?

Correct Answer is B

Explanation

A nurse is preparing to administer haloperidol 0.5 mg by mouth to an older adult client. The amount available is haloperidol oral concentrate 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.25"]

Explanation

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Exhibits

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

Select all that apply.