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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

A. Initiate a 1:1 observation status B. Point out the behavior as unacceptable C. Ask the patient why they are behaving that way D. Have the patient return to his room

Correct Answer is B

Explanation

A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.

B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.

C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.

D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.

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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?

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Naxlex Comprehensive Predictor Exams

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