Nokea
The client is one (1) hour postoperative thyroidectomy. Which intervention should the nurse implement?
- A. Check the posterior neck for bleeding.
- B. Assess the client for the Chvostek's sign.
- C. Monitor the client's serum calcium level.
- D. Change the client's surgical dressing.
Correct Answer: A
Rationale: Checking for bleeding on the posterior neck prevents hematoma, a critical post-thyroidectomy complication. Chvostek’s, calcium, and dressing changes are secondary.
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The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse?
- A. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation.
- B. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22.
- C. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28.
- D. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.
Correct Answer: C
Rationale: Addison’s with hypotension (80/45), tachycardia (124), and lethargy suggests adrenal crisis, requiring an experienced nurse. Ventilator care, stable Cushing’s, and post-thyroidectomy are less acute.
The nurse receives orders for the newly admitted client with Addison's disease. Which orders should the nurse question with the HCP? Select all that apply.
- A. Potassium 20 mEq oral now
- B. Sodium-restricted diet of 1000 mg
- C. Serum cortisol level in early am.
- D. Obtain serum glucose level now
- E. 5% dextrose in NS at 100 mL/hr
Correct Answer: A,B
Rationale: Potassium administration and a sodium-restricted diet are inappropriate as Addison's disease causes hyperkalemia and hyponatremia.
The 68-year-old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client?
- A. Explain it will take up to a month for symptoms of hyperthyroidism to subside.
- B. Teach the iodine therapy will have to be tapered slowly over one (1) week.
- C. Discuss the client will have to be hospitalized during the radioactive therapy.
- D. Inform the client after therapy the client will not have to take any medication.
Correct Answer: A
Rationale: Radioactive iodine takes weeks to reduce hyperthyroid symptoms, requiring client understanding. Tapering, hospitalization, and stopping medications are incorrect.
The client is diagnosed with hypothyroidism. Which assessment data support this diagnosis?
- A. The client's vital signs are: T 99.0, P 110, R 26, and BP 145/80.
- B. The client complains of constipation and being constantly cold.
- C. The client has an intake of 780 mL and output of 256 mL.
- D. The client complains of a headache and has projectile vomiting.
Correct Answer: B
Rationale: Constipation and cold intolerance are classic hypothyroidism symptoms due to slowed metabolism. Tachycardia/hypertension, fluid imbalance, and vomiting are unrelated.
What is the best way to assess for hemorrhage in a client who has had a thyroidectomy?
- A. Check the pulse and blood pressure hourly.
- B. Roll the client to the side and check for evidence of bleeding.
- C. Ask the client if he/she feels blood trickling down the back of the throat.
- D. Place a hand under the client's neck and shoulders to feel bed linens.
Correct Answer: D
Rationale: Placing a hand under the neck and shoulders detects blood pooling under the incision, a common site for post-thyroidectomy hemorrhage.