Nokea
A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, 'I feel numbness and tingling around my mouth.' What action should the nurse take?
- A. Offer mouth care
- B. Loosen the dressing
- C. Assess for Chvostek's sign
- D. Ask the client orientation questions
Correct Answer: C
Rationale: Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse should assess for Chvostek's sign and Trousseau's sign to confirm hypocalcemia and notify the provider.
You may also like to solve these questions
A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?
- A. Reassure the client that the voice change is temporary
- B. Notify the provider immediately
- C. Place the client in a high-Fowler's position and apply oxygen
- D. Prepare for emergency intubation
Correct Answer: D
Rationale: Stridor is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. The nurse should place the client in a high-Fowler's position and apply oxygen to maintain the airway while preparing to assist with emergency intubation or tracheostomy and notifying the provider or Rapid Response Team.
A nurse assesses a client with hyperthyroidism who is prescribed lithium carbonate. Which assessment finding should alert the nurse to a side effect of this therapy?
- A. Blurred and double vision
- B. Increased thirst and urination
- C. Increased thirst and double vision
- D. Decreased attention and insomnia
Correct Answer: B
Rationale: Lithium antagonizes antidiuretic hormone and can cause symptoms of diabetes insipidus. This manifests with increased thirst and urination. Lithium has no effect on vision, gastric upset, or level of consciousness.
A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this client's plan of care?
- A. Monitor the electrolyte measurement once every shift
- B. Administer acetaminophen (Tylenol) for fever
- C. Ensure that working suction equipment is in the room
- D. Provide supplemental oxygen as needed
Correct Answer: C
Rationale: Clients with hypothyroidism and concurrent illness like pneumonia are at risk for myxedema coma, where maintaining an airway is critical. Ensuring working suction equipment is available is a priority to manage potential airway obstruction.
A nurse plans care for a client with hyperparathyroidism. Which intervention should the nurse include in this client's plan of care?
- A. Ask the client to ambulate in the hallway twice a day
- B. Use a lift sheet to assist the client with position changes
- C. Provide the client with a soft-bristled toothbrush for oral care
- D. Instruct the unlicensed assistive personnel to strain the client's urine for stones
Correct Answer: B
Rationale: Hyperparathyroidism increases calcium resorption from bones, raising the risk of pathologic fractures. Using a lift sheet reduces the risk of bone injury during movement. Ambulation and oral care are not specific to this condition, and not all clients require urine straining.
A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium 7.2 mg/dL, Sodium 144 mEq/L, Magnesium 1.2 mEq/L, Potassium 5.7 mEq/L. Based on these results, which medications should the nurse anticipate administering?
- A. Oral potassium chloride
- B. Intravenous calcium chloride
- C. 50% normal saline IV solution
- D. 50% magnesium sulfate
- E. Oral calcitriol (Rocaltrol)
Correct Answer: B,D
Rationale: The client has hypocalcemia (calcium 7.2 mg/dL) and hypomagnesemia (magnesium 1.2 mEq/L), requiring intravenous calcium chloride and magnesium sulfate. Potassium is elevated, so potassium chloride is not needed. Sodium is normal, so saline is unnecessary, and no vitamin D deficiency is indicated.