The nurse is assessing a patient with a cochlear implant and notices that there is drainage, swelling, and tenderness behind the ear with the implant. What is the priority nursing intervention?
Anticipate a medical prescription for a hearing test
Obtain a culture of the drainage
Remove any foreign body from the ear canal
Obtain a medical prescription for a CT of the skull
The Correct Answer is B
A. A hearing test does not address the infection symptoms and would not be the priority.
B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.
C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.
D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
Correct Answer is A
Explanation
A. Neurogenic shock occurs in spinal cord injuries above T6 and is characterized by hypotension, bradycardia, and loss of sympathetic tone below the level of injury. This condition results from disruption of autonomic pathways.
B. Brain herniation typically involves increased intracranial pressure and different neurological symptoms.
C. Spinal shock involves temporary loss of reflexes and sensation but does not specifically cause bradycardia or hypotension.
D. Autonomic dysreflexia involves sudden high blood pressure and is usually triggered by noxious stimuli, occurring after the acute phase of SCI.
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