A nurse observes shoulder drop postoperatively in a client who had a radical neck dissection for cancer 24 hours ago. What is the nurse's best action?
A. Reposition the client on the nonoperative side.
B. Document the observation as the only action.
C. Assess deep tendon reflexes.
D. Notify the physician.
B
Cranial nerve XI (spinal accessory nerve) is removed during a radical neck dissection. The re-sulting shoulder drop is an expected side effect. Physical therapy exercises are essential later in the recovery period, but no specific interventions are required at this postoperative stage.
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