The nurse is caring for a client who had a bowel resection 2 hours ago for adenocarcinoma removal. It would be necessary for the nurse to immediately notify the surgeon if the client's assessment revealed:
no bowel sounds noted during the assessment.
an SPO2 which registers 90% while the client is asleep.
increasing abdominal distention.
a small amount of green-tinged fluid from the nasogastric tube.
The Correct Answer is C
A. The absence of bowel sounds shortly after surgery is not uncommon, especially within the first few hours, and does not necessarily indicate a complication at this time.
B. An SPO2 of 90% while the client is asleep may warrant attention, but it is not as critical as signs of a potential surgical complication. The nurse should assess the patient's respiratory status and consider interventions, but immediate notification to the surgeon is not required.
C. Increasing abdominal distention is a concerning sign that may indicate complications such as an anastomotic leak or bowel obstruction, which requires immediate evaluation and possible intervention by the surgeon.
D. A small amount of green-tinged fluid from the nasogastric tube is generally expected postoperatively and does not necessarily indicate a problem, thus does not require immediate notification of the surgeon.
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Correct Answer is B
Explanation
A. An otoscope is used to examine the ear canal and tympanic membrane, not to assess cranial nerve III. This tool is more relevant for assessing cranial nerve VIII (vestibulocochlear), which is responsible for hearing and balance.
B. A penlight is used to assess CN III (oculomotor) by evaluating the pupil's response to light and the ability to move the eye. This nerve controls most of the eye's movements, including constriction of the pupil in response to light.
C. A cotton ball is used to test the sensory function of cranial nerve V (trigeminal), which is responsible for facial sensation. It is not used for assessing CN III.
D. Lavender or other scents may be used to test CN I (olfactory), responsible for the sense of smell, but it is not related to CN III, which governs eye movements and pupil reactions.
Correct Answer is C
Explanation
A. A lesion of cranial nerve IX primarily affects swallowing and taste sensations rather than motor coordination or balance, so this is unlikely to explain the patient's symptoms.
B. Vestibular disease typically results in vertigo and balance issues, but the specific observations of slow alternating movements and loss of balance during the Romberg Test suggest a different underlying cause.
C. Dysfunction of the cerebellum would explain the patient's difficulties with rapid alternating movements and balance issues, as the cerebellum is responsible for coordinating motor activity and maintaining posture and balance. This aligns with the assessment findings, indicating a probable cerebellar dysfunction.
D. While an AVM in the frontal lobe could affect motor control, the specific symptoms presented, such as the inability to perform rapid movements and balance issues, are more characteristic of cerebellar dysfunction rather than a frontal lobe lesion.