Nurses' Notes Preoperative 0730: The client is scheduled for a left stapedectomy. Pupils 3.5 mm, equal, round, and reactive to light. Smile symmetrical. Mucous membranes show color expected for the client's skin tone and moisture. Speech clear. Skin warm and dry. Lungs clear bilaterally. Apical heart rate regular at 78/min. Postoperative 1230: Pupils were 3 mm, equal, and reactive to light. Smile asymmetrical. Mucous membranes pink. Speech hoarse. Client with left facial droop Skin warm and dry. The client reports vertigo and nausea. Bilateral breath sounds clear and present throughout. Apical heart rate regular at 92/min. The client reports left ear discomfort and rates the pain as 5 on a scale of 0 to 10. The client states that her hearing has diminished following surgery. Which of the following findings requires further action by the nurse? Select all that apply.
Explanation & Rationale
A. Vertigo is common after inner ear surgery like stapedectomy and can be related to changes in the inner ear. It should be monitored, but it's not an immediate concern unless severe. B. Correct. A change in facial symmetry (left facial droop) is indicative of potential facial nerve dysfunction, which requires immediate attention. C. Pupils are reactive to light, and their size is within the expected range, indicating normal pupillary function. D. A pain rating of 5 on a scale of 0 to 10 indicates moderate pain. While it requires attention, it's not a critical concern. E. Correct. Diminished hearing following ear surgery is an expected finding, but the nurse should assess the degree and type of hearing loss and communicate this to the healthcare provider. F. Lung assessment is important but does not require immediate action based on the given information.