What does a nurse assess postoperatively in a client with a nasal fracture?

Correct Answer: C

Rationale: Postoperatively in a client with a nasal fracture, a nurse would assess for airway obstruction. Nasal fractures can cause swelling, bleeding, and obstruction of the nasal passages, which could potentially compromise the client's ability to breathe. Monitoring for signs of airway compromise, such as difficulty breathing, stridor, or other respiratory distress, is crucial in the postoperative period to ensure prompt intervention if necessary. Assessing for airway patency is a priority to prevent any serious complications related to impaired breathing. While allergic reaction, extreme sense of smell, or stridor may occur in some cases, airway obstruction is the most critical concern that requires immediate attention to maintain the client's respiratory function.

Correct Answer: D

Rationale: Egocentric thinking is characteristic of preschool-age children.

Correct Answer: B

Rationale: Decorticate posturing is characterized by flexion of elbows, wrists, and fingers; extension of elbows and knees; plantar flexion of the feet. This type of posturing typically indicates severe damage to the cerebral hemispheres or impairment of the corticospinal tract. When a client with increased intracranial pressure (ICP) displays decorticate posturing, it suggests significant brain injury and dysfunction. This abnormal posturing is a classic sign that requires immediate medical attention and intervention.

Correct Answer: B

Rationale: For an agitated head-injured patient, the most therapeutic setting would be a semiprivate room with one or two consistent caregivers. Consistency and familiarity can help reduce agitation and promote a sense of security for the patient. A quieter environment with fewer stimuli can also help in managing agitation and promoting a sense of calmness. By having consistent caregivers, the patient can build trust and feel more comfortable, which can contribute to their overall well-being and recovery. It is essential to minimize external factors that could contribute to further agitation, making a semiprivate room with consistent caregivers the most optimal setting for an agitated head-injured patient.

Correct Answer: D

Rationale: The anesthesiologist is responsible for transferring the patient to the postanesthesia care unit (PACU) after the surgical incision has been closed and the anesthesia has worn off. The anesthesiologist ensures that the patient is stable and ready for transfer, including assessing vital signs and overall condition. Due to their specialized training in anesthesia and perioperative care, the anesthesiologist is best equipped to manage the transition of care from the operating room to the PACU, where the patient will continue to be monitored closely during the immediate postoperative period.