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.
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Related Questions
Correct Answer is D
Explanation
A. Incorrect. Epinephrine is not used to treat hyperglycemia.
B. Incorrect. Epinephrine is not used to treat hand tremors.
C. Incorrect. Epinephrine is not used to treat nausea.
D. Correct. Epinephrine is used to treat severe allergic reactions, including anaphylaxis, which can involve manifestations such as shortness of breath, difficulty breathing, and wheezing.
Correct Answer is A
Explanation
A. Correct. This response acknowledges the client's feelings and demonstrates empathy. It opens the door for further discussion and exploration of the client's beliefs without immediately challenging them.
B. Incorrect. Directly contradicting the client's beliefs may cause resistance and increase their distress. It's important to approach the situation with sensitivity and understanding.
C. Incorrect. While asking for clarification is a valid approach, it may not be the most appropriate initial response. It's important to establish trust and rapport with the client before delving into their delusional beliefs.
D. Incorrect. Asking "why" s may put the client on the defensive and may not lead to a productive conversation about their beliefs. It's better to approach the situation with empathy and openness before exploring the client's perspective.
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