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 D
Explanation
A. Increased insulin production would not cause polyuria and low specific gravity urine; rather, hyperglycemia from lack of insulin can cause high specific gravity due to glucose in urine.
B. Increased ACTH affects cortisol production but is not directly related to urine concentration or polyuria.
C. Low T3 and T4 levels are associated with hypothyroidism, which typically does not cause polyuria or decreased specific gravity.
D. Insufficient ADH, as seen in diabetes insipidus, leads to the inability to concentrate urine, resulting in a low specific gravity, polyuria, and nocturia due to excessive water loss.
Correct Answer is B
Explanation
A. The Glasgow Coma Scale is useful for assessing consciousness levels but may not be as sensitive for changes in brainstem function in a patient already in an induced coma.
B. Assessing pupillary size and reaction provides critical information on brainstem function and can indicate changes in ICP. Changes in pupil size and reaction can signify worsening cerebral function or brain herniation.
C. Blood pressure and heart rate are vital signs that can suggest increased ICP, but they are not as direct an indicator of cerebral function as pupil assessment.
D. The gag reflex is important but does not provide as direct information about cerebral function related to ICP as pupillary assessment does.