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 D

Explanation

A. "I will wipe away yellow crusts that form around the incision." Yellow crusting at the incision site is a normal part of the healing process. It should not be wiped away, as doing so could disrupt healing and cause irritation or bleeding. Instead, the area should be kept clean and allowed to heal naturally.
B. "I will apply antibiotic ointment to my baby's penis." The Plastibell technique does not require the application of antibiotic ointment. Unlike other circumcision methods, the Plastibell ring remains in place and falls off on its own within 5 to 8 days, reducing the need for additional topical treatments.
C. "I will make sure that my baby's diaper is applied snugly." The diaper should be applied loosely to prevent excessive pressure or friction on the healing area. A snug diaper can cause discomfort and increase irritation, potentially delaying healing.
D. "I will apply pressure with gauze if I see bleeding." Minor bleeding may occur after circumcision, and applying gentle pressure with sterile gauze is the appropriate action to control it. If bleeding persists beyond a few minutes or is excessive, medical attention should be sought immediately.

A. Disorientation B. Paresthesias C. Sleep apnea D. Tonic-clonic seizures

Correct Answer is A

Explanation

A. Disorientation. Temporary confusion and disorientation are common immediately after electroconvulsive therapy (ECT). This occurs due to the brief, induced seizure affecting brain activity. Clients may also experience short-term memory impairment, but orientation typically improves within minutes to hours.
B. Paresthesias. Abnormal sensations such as tingling or numbness are not expected effects of ECT. While muscle soreness may occur due to seizure activity, paresthesias are not a typical post-procedure finding.
C. Sleep apnea. ECT does not cause sleep apnea. However, clients with pre-existing sleep apnea may require careful monitoring due to anesthetic agents used during the procedure, which could temporarily depress respiratory function.
D. Tonic-clonic seizures. ECT induces a controlled seizure lasting about 30 to 60 seconds, but spontaneous seizures should not occur afterward. If a client experiences an unprovoked seizure post-ECT, further evaluation is needed to rule out underlying neurological conditions.

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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

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Correct Answer is D

Explanation

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Explanation

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Exhibits

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

Select all that apply.