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 C

Explanation

A. Peeling of the hands and feet is not a common manifestation of pertussis. This symptom is typically associated with other conditions, such as Kawasaki disease or toxic shock syndrome, rather than an infection caused by Bordetella pertussis.
B. Beefy, red tongue is usually seen in conditions like scarlet fever or certain nutritional deficiencies, such as vitamin B12 deficiency. It is not characteristic of pertussis and does not align with the typical clinical presentation of this respiratory illness.
C. Fever is a common manifestation of pertussis, especially in the early stages. The child may present with a mild to moderate fever as the immune system responds to the infection. Fever can help in distinguishing pertussis from other respiratory illnesses, especially in conjunction with the classic coughing fits.
D. Facial erythema is not typically seen in pertussis. While some flushing may occur during intense coughing episodes, it is not a primary symptom. Pertussis is more characterized by severe coughing fits, the distinctive "whoop" sound during inspiration, and potential vomiting after coughing.

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

Correct Answer is D

Explanation

A. Recurring urinary tract infections. Chronic infections act as internal stressors because they arise from within the body, leading to physical discomfort and emotional strain. While they can contribute to stress, they do not originate from an external source, such as environmental or situational factors.
B. Report of feeling depressed. Depression is an internal emotional state rather than an external stressor. Although it can be triggered by external events, depression itself comes from psychological and physiological processes within the individual rather than from outside influences.
C. Lack of nutritional knowledge. Limited knowledge about nutrition is an internal factor affecting decision-making rather than an external stressor. External stressors involve changes in one's environment or circumstances that create pressure, whereas knowledge gaps influence behavior but do not directly impose stress from an outside source.
D. A recent move to a new city. Moving to a new city is an external stressor as it involves environmental change, social adaptation, and logistical challenges. Adjusting to a new home, job, or social network can be overwhelming, increasing stress levels due to uncertainty, unfamiliar surroundings, and the need for adjustment.

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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 collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is C

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 D

Explanation

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A nurse is assisting with the care of a client. Exhibits For each data collection finding, dick to specify if the finding is consistent with ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

Exhibits

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

Select all that apply.