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Which of the following findings requires further action by the nurse? Select all that apply.

Lung assessment

Vertigo

Facial nerve assessment

Pain rating

Diminished hearing

Pupils

Answer and Explanation

Correct Answer : B,C,D,E

Lung assessment: The client's lungs are clear bilaterally with no signs of respiratory distress or abnormal breath sounds. There is no indication of pulmonary complications, so no further immediate action is needed regarding the lung assessment.
Vertigo: Vertigo is a common complication following a stapedectomy due to disturbance of the inner ear structures. However, it still requires monitoring because severe or worsening vertigo can increase the risk of falls and indicate inner ear trauma or dysfunction.
Facial nerve assessment: The presence of left facial droop and asymmetrical smile indicates possible injury to the facial nerve during surgery. This finding is abnormal and requires immediate provider notification for further neurological evaluation and management.
Pain rating: A pain rating of 5 out of 10 is moderate and, following ear surgery, it should be addressed. Proper pain control is important not only for comfort but also to reduce the risk of increased intracranial pressure from straining or agitation.
Diminished hearing: Some decrease in hearing can occur temporarily after a stapedectomy due to packing or swelling, but it still needs further monitoring. Persistent or worsening hearing loss could suggest a surgical complication, such as prosthesis dislocation.
Pupils: The pupils are equal, smaller postoperatively but still reactive to light, which is expected following anesthesia and is not concerning. No immediate intervention is necessary based on pupil assessment findings.

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Correct Answer is A

Explanation

A. Place the client in a room near the nurses' station: Clients with quadriplegia are at high risk for complications such as respiratory difficulties, pressure injuries, and autonomic dysreflexia. Placing them near the nurses’ station allows for closer monitoring and quicker response to any urgent needs.

B. Check on the client every 4 hr: Clients with quadriplegia require more frequent monitoring than every 4 hours. Regular repositioning, skin assessments, and prompt attention to needs must occur at much shorter intervals to prevent complications.

C. Place the call light within the client's reach: A client with quadriplegia typically has limited or no use of their upper extremities. Therefore, they would be unable to effectively use a standard call light and would need alternative methods, such as a specialized call device.

D. Place the client's glasses on the bedside table: If the client is unable to move their arms due to quadriplegia, placing glasses on the bedside table would not be useful. Necessary personal items should be made accessible through assistance or adaptive equipment.

A. “I have nosebleeds once per week" B. "My heart feels like it skips a beat” C. “I am experiencing persistent headaches." D. The palms of my hands are red and blotchy”

Correct Answer is C

Explanation

A. "I have nosebleeds once per week.": Occasional nosebleeds are relatively common during pregnancy due to hormonal changes causing increased vascularity and congestion of the nasal passages. While the frequency should be noted, it's generally not a priority to report unless they are severe, frequent, or difficult to control.

B. "My heart feels like it skips a beat.": Palpitations can occur during pregnancy because of increased blood volume and changes in cardiovascular function. Occasional palpitations are typically benign but should be further evaluated if they become persistent or are associated with other symptoms like chest pain.

C. "I am experiencing persistent headaches.": Persistent headaches during pregnancy, especially after 20 weeks gestation, can be a warning sign of preeclampsia, a serious hypertensive disorder. Reporting this symptom immediately is critical to assess for elevated blood pressure, proteinuria, and other complications.

D. "The palms of my hands are red and blotchy.": Red, blotchy palms, known as palmar erythema, are a common and harmless finding during pregnancy due to increased estrogen levels. It does not usually indicate any serious condition and does not require urgent reporting.

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Which of the following findings requires further action by the nurse? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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