The nurse is caring for a client who has undergone a cataract extraction and during the early postoperative period is complaining of nausea and severe eye pain over the operative site. What should be the initial nursing action?
Turn the client onto their operative side.
Administer the prescribed pain medication and antiemetic.
Call the surgeon.
Reassure the client that this is normal.
The Correct Answer is B
A. Turning the client onto their operative side could increase pressure on the eye and is not an appropriate first action.
B. Administering prescribed pain medication and antiemetic is essential to address the client's severe pain and nausea, which are priority concerns in the postoperative period.
C. While it may be necessary to notify the surgeon if symptoms persist, the immediate priority is to alleviate the client's discomfort.
D. Reassuring the client that these symptoms are normal is misleading; severe pain and nausea postoperatively should be addressed promptly.
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Correct Answer is ["A","B","D"]
Explanation
A. Hypertension can occur due to autonomic dysreflexia, especially in clients with cervical spinal cord injuries, as they may have exaggerated sympathetic responses.
B. A weakened gag reflex can result from cranial nerve involvement due to the cervical spinal cord injury, impacting the client's ability to protect their airway.
C. Absence of bowel sounds may indicate bowel immobility or dysfunction; however, it is not a direct complication of a cervical spinal cord injury.
D. Bradycardia is a common finding in cervical spinal cord injuries due to impaired sympathetic nervous system function, leading to decreased heart rate.
E. Tachycardia is less common in cervical injuries and is typically associated with lower injuries in the spinal cord.
Correct Answer is A
Explanation
A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.