Nokea
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.
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A nurse assesses clients for potential endocrine disorders. Which client is at greatest risk for hyperparathyroidism?
- A. A 20-year-old female with pregnancy-induced hypertension
- B. A 41-year-old male receiving dialysis for end-stage kidney disease
- C. A 41-year-old male receiving dialysis for end-stage kidney disease
- D. A 27-year-old male who is prescribed home oxygen therapy
Correct Answer: B
Rationale: Clients with chronic kidney disease have impaired vitamin D activation and calcium absorption, leading to chronic hypocalcemia, which overstimulates the parathyroid glands, causing hyperparathyroidism. Pregnancy-induced hypertension and oxygen therapy do not increase this risk.
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 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.
A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this client's education?
- A. Do not share utensils, plates, or cups with anyone
- B. You can play with your grandchildren for 1 hour each day
- C. Eat foods high in vitamins such as apples, pears, and oranges
- D. Avoid contact with pregnant women and children
- E. Take a laxative 2 days after therapy to excrete the radiation
Correct Answer: A,D,E
Rationale: Clients receiving unsealed radioactive isotopes must avoid sharing utensils, contact with pregnant women and children, and take laxatives on days 2 and 3 to excrete radiation. Playing with grandchildren and eating specific fruits are not recommended due to radiation safety concerns.
A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client's blood pressure, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?
- A. Serum potassium: 5.2 mEq/L
- B. Serum magnesium: 1.7 mEq/L
- C. Serum sodium: 144 mEq/L
- D. Serum calcium: 6 mg/dL
Correct Answer: D
Rationale: Hypocalcemia, indicated by a serum calcium level of 6 mg/dL, destabilizes excitable membranes, leading to muscle spasms and tetany, such as Trousseau's sign (flexion contractions). Potassium, magnesium, and sodium levels listed are not directly related to this condition.