The Nurse Is Assessing a Patient Who Has Just Arrived

question 22

Multiple Choice

The nurse is assessing a patient who has just arrived in the postanesthesia recovery area (PACU) after a blepharoplasty. Which of these assessment data will require the most immediate action by the nurse?

• A) The patient complains of incision discomfort at a level 5 of a 10-point scale.
• B) The cardiac monitor shows a heart rate of 110 beats/minute.
• C) The patient is unable to detect when the eyelids are touched.
• D) The skin around the eye incisions is pale and cool to palpation.

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Definitions:

Electrical Charge

A physical property that causes matter to experience a force when placed in an electromagnetic field, categorized as positive, negative, or neutral.

Sensory Neurons

Specialized neurons responsible for converting external stimuli from the environment into internal electrical impulses for the brain.

Sense Organs

Body parts responsible for receiving and processing sensory stimuli (eyes, ears, nose, skin, and tongue).

Spinal Cord

The spinal cord is a long, thin, tubular structure made up of nervous tissue, which extends from the medulla oblongata in the brainstem to the lumbar region of the vertebral column. It transmits nerve signals from the brain to the rest of the body.