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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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

Anticipated:

Pyrazinamide: This is a first-line anti-tuberculosis medication used in combination therapy to treat active TB. It helps shorten treatment duration and targets intracellular bacteria.
Contact precautions: TB is transmitted via airborne droplets, requiring airborne precautions instead. However, contact precautions can still be implemented in addition to airborne precautions.
Ethambutol: This medication is used to prevent resistance and is part of the standard four-drug regimen for active tuberculosis.
Isoniazid: A core component of TB treatment, isoniazid is effective against actively dividing Mycobacterium tuberculosis. It is typically given for at least 6 months.
Airborne precautions: TB is transmitted through airborne droplets, necessitating airborne precautions such as an N95 mask, negative-pressure isolation, and limiting client transport.
Rifampin: Another first-line anti-tuberculosis drug, rifampin works by inhibiting bacterial RNA synthesis and is a crucial part of combination therapy for TB.

Contraindicated:

Monthly TB skin test for 1 year: Once TB is confirmed via sputum culture and chest x-ray, repeated skin testing is unnecessary and would not provide additional diagnostic value.

A. "You will suffer serious health issues if you don't take your medication." B. "I'd like to hear your thoughts about giving yourself this medication." C. "Have you considered how your decision to refuse medication will affect your family?" D. "Why don't you want to learn how to give yourself your medication?"

Correct Answer is B

Explanation

A. "You will suffer serious health issues if you don't take your medication." While it is important to convey the seriousness of diabetes management, this statement may come across as threatening or coercive. It does not encourage open communication or exploration of the client's feelings about their diagnosis or treatment.
B. "I'd like to hear your thoughts about giving yourself this medication." This response invites the client to express their feelings and concerns about self-administering insulin. It promotes open dialogue and allows the nurse to understand the client’s perspective, fears, or misconceptions, which can help tailor the education and support provided.
C. "Have you considered how your decision to refuse medication will affect your family?" While family considerations can be important, this response may place undue pressure on the client and shift focus away from their personal feelings about their treatment. It does not foster a supportive environment for the client to share their concerns.
D. "Why don't you want to learn how to give yourself your medication?" This question may come across as confrontational or judgmental. Instead of encouraging a collaborative discussion, it might make the client defensive. It’s essential to create a safe space for clients to share their thoughts and feelings.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

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

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Naxlex Comprehensive Predictor Exams

The nurse reviews the client's test results. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}

Explanation

A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer insulin. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

The nurse is reviewing the client's medical record. Exhibits For each potential nursing action, click to specify if the action is indicated or not indicated.

A nurse is reinforcing discharge teaching with a client who had a right total hip arthroplasty. Which of the following instructions should the nurse include?

A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is scheduled for an intravenous pyelogram. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who has diabetes mellitus and is taking insulin lispro and insulin glargine. Which of the following instructions should the nurse include in the teaching?

A nurse is assisting in the care of a client. Exhibits Which of the following interventions should the nurse plan to implement? Select all that apply.

Exhibits

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

Select all that apply.