The nurse is concerned that a patient recovering from a ...

[washai]

The nurse is concerned that a patient recovering from a thymectomy is developing a pneumothorax. What did the nurse assess to cause this concern?
 
  Select all that apply.
 
  1. shortness of breath
  2. decreased breath sounds
  3. sudden onset of chest pain
  4. coughing pink-tinged mucous
  5. pain level 5 on a scale from 0 to 10

Question 2

The nurse is caring for a patient recovering from a percutaneous rhizotomy for trigeminal neuralgia. What techniques should the nurse use to assess this patient for adverse effects from the procedure?
 
  Select all that apply.
 
  1. clench the teeth
  2. touch the cornea with a cotton wisp
  3. stick out the tongue
  4. place sugar on the front of the patient's tongue
  5. move the eyes through the cardinal positions of vision

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Answer to Question 1

Correct Answer: 1, 2, 3
Patients with a thoracotomy and sternal split procedure will require care of the anterior chest tube. Observe for complications, such as pneumothorax. Air may enter the thoracic cavity causing sudden chest pain, dyspnea, and decreased breath sounds. Pink-tinged mucous is not an indication of a hemothorax. Pain level 5 on a scale from 0 to 10 would be expected after a thoracotomy.

Answer to Question 2

Correct Answer: 1, 2, 4, 5
Assess the motor portion of the trigeminal nerve by asking the patient to clench the teeth while the tightness of the contracted masseter and temporal muscles is palpated. Loss of motor function is indicated by loss of bulk and tightness of these muscles. Assess the corneal reflex by lightly touching the cornea with a wisp of cotton. If the reflex is intact, the patient will blink. Severing the ophthalmic division of the trigeminal nerve destroys the corneal reflex and leaves the cornea at risk for dryness and injury. Sticking out the tongue assesses the function of the hypoglossal nerve and not the trigeminal nerve. Test taste by placing bitter, salty, and sweet substances on the anterior portion of the tongue. The facial nerve also innervates the anterior two-thirds of the tongue. Assess the function of the oculomotor muscles by asking the patient to follow a finger through the cardinal positions of vision. The eyes should move together; alterations in movement indicate an abnormal response.

[washai]

Gracias!

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