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.
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Correct Answer is D
Explanation
A. Bradycardia is possible due to autonomic dysfunction but is not the leading cause of death.
B. Sepsis can occur due to immobility and pressure injuries but is secondary to respiratory compromise.
C. Hypertension is not directly linked to high cervical spine injuries and is less common than respiratory issues in this setting.
D. Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing. Mechanical ventilation is often required to maintain adequate oxygenation.
Correct Answer is B
Explanation
A. Scheduled voiding is less effective in patients with a flaccid bladder because there is no voluntary control of bladder function.
B. Intermittent catheterization is the preferred management technique for a flaccid or atonic bladder, allowing the bladder to empty at regular intervals and reducing the risk of infection associated with continuous catheters.
C. An indwelling catheter is usually avoided for long-term use due to a higher risk of infection.
D. An external catheter is generally not effective for flaccid or atonic bladder management in spinal cord injuries as it doesn’t actively empty the bladder.