Nokea
The afternoon following a thyroidectomy, the client experiences all of the following. Which one indicates to the nurse that the client is experiencing a serious complication?
- A. A sore throat
- B. Pain at the surgical site
- C. Temperature of 100.2°F
- D. Sudden hoarseness
Correct Answer: D
Rationale: Sudden hoarseness post-thyroidectomy may indicate vocal cord paralysis or hematoma compressing the airway, a serious complication requiring immediate attention. Sore throat, surgical pain, or mild fever are expected.
You may also like to solve these questions
A veteran is admitted with a diagnosis of chronic post-traumatic stress disorder. After being placed in the treatment room, he begins to pace frantically and make references to 'highway one.' As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tight to his body. The client is experiencing a:
- A. Hallucination
- B. Phobic reaction
- C. Delusion
- D. Flashback
Correct Answer: D
Rationale: The behavior and reference to 'highway one' suggest a flashback, where the client is reliving a traumatic event, common in PTSD.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client’s current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: Medication adherence is the most critical factor to assess in uncontrolled hypertension (170/94 mm Hg), as non-compliance is a common cause. Stress, diet, and smoking are secondary.
The nurse knows that the mother understands the dietary instructions for her toddler who has iron deficiency anemia when the mother selects which foods?
- A. Whole milk, carrots, and chicken pieces
- B. Ground beef, broccoli, and orange juice
- C. Liver, lima beans, and skim milk
- D. Macaroni and cheese, peas, and cola
Correct Answer: B
Rationale: Ground beef and broccoli are iron-rich, and orange juice (vitamin C) enhances iron absorption, ideal for iron deficiency anemia. Milk-heavy diets can inhibit iron absorption.
The nurse is reinforcing teaching about nutrition with the parents of a 6-year-old client with cystic fibrosis. Which recommended diet should the nurse include?
- A. High calorie, high protein
- B. High carbohydrate, low fiber
- C. Low fat, low sodium
- D. Low phosphate, low protein
Correct Answer: A
Rationale: Cystic fibrosis requires a high-calorie, high-protein diet to support growth and compensate for malabsorption. Other diets do not meet the increased nutritional demands.
A client with a history of asthma is admitted with severe shortness of breath and cyanosis. Which finding would indicate that the client is experiencing status asthmaticus?
- A. Increased vocal fremitus
- B. Silent chest on auscultation
- C. Stridor during inspiration
- D. Rhonchi in bilateral lung fields
Correct Answer: B
Rationale: Silent chest on auscultation indicates severe airway obstruction with minimal air movement, a hallmark of status asthmaticus, requiring immediate intervention.