Nurses' Notes Preoperative 0730:
The client is scheduled for a left stapedectomy.
Pupils 3.5 mm, equal, round, and reactive to light. Smile symmetrical.
Mucous membranes show color expected for the client's skin tone and moisture.
Speech clear.
Skin warm and dry. Lungs clear bilaterally.
Apical heart rate regular at 78/min. Postoperative
1230:
Pupils were 3 mm, equal, and reactive to light.
Smile asymmetrical. Mucous membranes pink. Speech hoarse.
Client with left facial droop Skin warm and dry.
The client reports vertigo and nausea.
Bilateral breath sounds clear and present throughout. Apical heart rate regular at 92/min.
The client reports left ear discomfort and rates the pain as 5 on a scale of 0 to 10. The client states that her hearing has diminished following surgery.
Which of the following findings requires further action by the nurse? Select all that apply.
Vertigo
Facial nerve assessment
Pupils
Pain rating
Diminished hearing
Lung assessment
Correct Answer : B,E
A. Vertigo is common after inner ear surgery like stapedectomy and can be related to changes in the inner ear. It should be monitored, but it's not an immediate concern unless severe.
B. Correct. A change in facial symmetry (left facial droop) is indicative of potential facial nerve dysfunction, which requires immediate attention.
C. Pupils are reactive to light, and their size is within the expected range, indicating normal pupillary function.
D. A pain rating of 5 on a scale of 0 to 10 indicates moderate pain. While it requires attention, it's not a critical concern.
E. Correct. Diminished hearing following ear surgery is an expected finding, but the nurse should assess the degree and type of hearing loss and communicate this to the healthcare provider.
F. Lung assessment is important but does not require immediate action based on the given information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Lightheadedness upon standing, also known as orthostatic hypotension, can be a common side effect of ACE inhibitors. Advising the client to sit down when experiencing lightheadedness will help prevent falls.
B. Incorrect. Discontinuing the medication without consulting a healthcare provider is not appropriate. Lightheadedness can be managed with strategies like changing positions slowly.
C. Incorrect. Restricting fluid intake is not necessary unless advised by a healthcare provider.
Adequate hydration is important, especially with the use of certain medications.
D. Incorrect. While potassium supplements might be prescribed in some cases with ACE inhibitors, the primary concern in this situation is addressing orthostatic hypotension.
Correct Answer is C
Explanation
The correct answer is choice c. “I am thankful I am done having children.”
Choice A rationale: This statement is incorrect because a vaginal hysterectomy involves the removal of the uterus, which means the client will no longer have menstrual periods.
Choice B rationale: This statement is incorrect because even after a hysterectomy, regular gynecological examinations are still necessary to monitor the health of the remaining reproductive organs and overall health.
Choice C rationale: This statement indicates that the client understands the implications of the surgery, specifically that they will no longer be able to have children, which is a key aspect of informed consent for a hysterectomy.
Choice D rationale: This statement is incorrect because a vaginal hysterectomy does not involve an abdominal incision, so there will not be a large scar on the stomach. The procedure is performed through the vagina.
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