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 B

Explanation

A. Loose stools are not a typical finding related to external radiation for throat cancer.
B. Correct. Loss of taste (dysgeusia. is a common side effect of radiation therapy, particularly in the treatment area?
C. Bladder infection is not a typical finding related to external radiation for throat cancer.
D. Increased appetite is not a common finding related to radiation therapy; it's more commonly associated with certain medications or hormonal changes.

A. Encourage the client to avoid caffeine. B. Report lithium level to the provider. C. Provide step-by-step reminders regarding hygiene. D. Involve the client in group activities. E. Encourage the client to eat finger foods frequently. F. Redirect aggressive behaviors G. Monitor the blood pressure and heart rate every 4 hr. H. Weigh the client daily.

Correct Answer is ["A","B","C","E","F","G","H"]

Explanation

A.Caffeine can exacerbate symptoms of mania by increasing restlessness and irritability. Avoiding caffeine can help in managing these symptoms.

B.Lithium is a common medication used to manage manic episodes in bipolar disorder. Monitoring lithium levels is crucial to ensure the client's safety and therapeutic effectiveness.

C.Clients experiencing mania may have difficulty focusing and completing tasks, including personal hygiene. Step-by-step reminders can help the client maintain proper hygiene.

D.While social interaction can be beneficial, clients in a manic state may become overstimulated or disruptive in group settings. Individual activities are often more appropriate until the mania is better controlled.

E.Clients in a manic state may be too restless to sit down for meals. Offering finger foods allows them to eat while on the go, helping to maintain adequate nutrition.

F.Clients with mania may exhibit aggressive behaviors. Redirecting these behaviors to safer or more appropriate outlets is important for the safety of the client and others.

G.The client's vital signs indicate an increase in heart rate and blood pressure, which are important to monitor closely as they can be affected by the heightened physical activity and agitation associated with mania.

H.Lithium can cause fluid retention and weight gain. Daily weight monitoring helps detect sudden increases that may indicate fluid imbalance or early signs of lithium toxicity. It also assists in managing and adjusting treatment as needed to prevent complications.

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Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","E","F","G","H"]

Explanation

A nurse is assisting with the care of a client and is collecting data from the client. Exhibits Select words from the choices below to fill in each blank in the following sentence. The nurse should identify that dropdown and dropdown indicate manifestations of borderline personality disorder

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

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

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

A nurse is assisting with the plan of care for a 10-month-old Infant who has HIV. Which of the following Interventions should the nurse Include in the plan?

A nurse is collecting data from a client during a routine prenatal visit. The client is in their second trimester of pregnancy and reports feeling dizzy, has a racing heart, and becomes pale while lying on their back. Which of the following actions should the nurse take?

A nurse is assisting in providing postmortem care for a client who was a devout follower of Hinduism. Which of the following requests should the nurse anticipate from the client's family?