Which assessment finding would require an immediate nursing action when providing care to an adolescent who is postoperative for spinal fusion surgery?
1. Sleeps when not bothered but arouses easily with stimuli
2. Impaired color, sensitivity, and movement to lower extremities
3. Nausea relieved by antiemetics
4. Pain relieved by analgesics
2
Explanation:
1. This is a normal response postanesthesia.
2. When the spinal column is manipulated, there is a risk for impaired color, sensitivity, and movement to lower extremities.
3. Nausea in the postoperative period is not uncommon, but it is not the priority at this time.
4. Pain is a common finding in the postoperative period and should be addressed, but impaired color, sensitivity, and movement of the lower extremities constitute the priority at this time.
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