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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Incorrect. While family medical history might provide some context, physical assessment findings are more directly relevant to a referral for a physical therapist.
B. Incorrect. Medical health insurance claims are administrative and financial information, not typically included in a referral for a physical therapist.
C. Correct. Physical assessment findings, such as range of motion limitations, mobility issues, gait abnormalities, and areas of pain or discomfort, are essential for a physical therapist to develop an appropriate plan of care.
D. Incorrect. Medications taken prior to admission might have some relevance, but physical assessment findings are crucial for a physical therapist to understand the client's physical condition.

A. "You should use patterned paced breathing when changing positions." B. "You can splint the incision with a pillow when changing positions." C. "You can apply counterpressure to your back with each position change." D. "You should change positions as little as possible."

Correct Answer is B

Explanation

A. Patterned-paced breathing might help with pain management, but it's not specific to changing positions.
B. Correct. Splinting the incision with a pillow provides support and reduces strain when changing positions, minimizing discomfort.
C. Counterpressure to the back might be helpful during contractions, but it's not specific to postoperative pain with position changes.
D. While reducing position changes might be initially suggested, it's important for postoperative clients to move to prevent complications like deep vein thrombosis. Providing strategies to manage pain during position changes is more appropriate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Correct Answer is C

Explanation

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?

A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following s is the nurse's priority?

A nurse in a long-term care facility is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA. Which of the following actions should the nurse take?