The nurse assesses a 3-year-old patient with a dried bean in the left ear canal. Which action should the nurse implement?
a. Wait for the bean to fall out.
b. Examine the ears with an otoscope.
c. Collaborate with the healthcare provider.
d. Irrigate the ear to flush out the bean.
C
The nurse inspects the ears visually without the aid of an otoscope to complete the nursing as-sessment and then collaborates with the healthcare provider to remove the bean. The bean is not likely to fall out because it is more likely to increase in size by being in the moist environment of the ear canal. The nurse avoids an otoscopic examination because inserting the otoscope into the ear canal is likely to affect the bean and make it harder to remove. The nurse avoids irrigating the patient's ear canal because the positive pressure from the irrigation solution is likely to affect the bean and make it harder to remove. In addition, a dried bean will absorb water, and its size will increase, further aggravating its removal.
You might also like to view...
A pediatric nurse is explaining child abuse and neglect to a class of nursing students. Which information does this nurse provide the students during the presentation? (Select all that apply.)
A. Children with disabilities are at higher risk. B. Diagnosing physical child abuse is easy and quick. C. Each week, about 5 children die from abuse. D. Neglect is most common, but is difficult to identify. E. Unexplained, recurrent conditions may be caused by abuse.
Being-in-the-world is a concept that is of relevance in case study research
A) True B) False
A client tells the nurse that she often comes home from work and "picks a fight" with her husband for no apparent reason. The nurse realizes this client is demonstrating the defense mechanism of:
a. projection. c. regression. b. repression. d. displacement.
The nurse has asked a child to rate her pain on a scale of 0 to 10 . The child ranks the pain at a 5 . The nurse will chart this in which of the following ways?
a. ranks pain at a 5 c. admits to a moderate level of pain b. states pain is at a 5 on a 10-point scale d. midpoint of scale in terms of pain