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The nurse is assessing a patient who has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy and obtains these data. Which of the following information is most important to communicate to the surgeon?
- A. The patient is sleepy and hard to arouse.
- B. The patient has increasing swelling of the neck.
- C. The patient is complaining of 7/10 incisional pain.
- D. The patient's cardiac monitor shows a heart rate of 112.
Correct Answer: B
Rationale: The neck swelling may lead to respiratory difficulty, and rapid intervention is needed to prevent airway obstruction. The incisional pain should be treated but is not unusual after surgery. A heart rate of 112 is not unusual in a patient who has been hyperthyroid and has just arrived in the PACU from surgery. Sleepiness in the immediate postoperative period is expected.
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The nurse is admitting a patient to the hospital who is in an Addisonian crisis. Which of the following patient statements support the nursing diagnosis of ineffective self-health management related to lack of knowledge about management of Addison's disease?
- A. I double my dose of hydrocortisone on the days that I go for a run.
- B. I frequently eat at restaurants, and so my food has a lot of added salt.
- C. I had the stomach flu earlier this week and couldn't take the hydrocortisone.
- D. I take twice as much hydrocortisone in the morning as I do in the afternoon.
Correct Answer: C
Rationale: The need for hydrocortisone replacement is increased with stressors such as illness, and the patient needs to be taught to call the health care provider because medication and IV fluids and electrolytes may need to be given. The other patient statements indicate appropriate management of the Addison's disease.
Which of the following findings for a patient who takes levothyroxine to treat hypothyroidism indicates that the nurse should contact the health care provider before administering the medication?
- A. Increased thyroxine (T4) level
- B. Blood pressure 102/62 mm Hg
- C. Distant and difficult to hear heart sounds
- D. Elevated thyroid stimulating hormone level
Correct Answer: A
Rationale: An increased thyroxine level indicates the levothyroxine dose needs to be decreased. The other data are consistent with hypothyroidism and the nurse should administer the Synthroid.
The nurse is admitting a patient with Graves' disease to the emergency department in thyrotoxic crisis. Which of these prescribed medications should the nurse administer first?
- A. Propranolol
- B. Propylthiouracil
- C. Methimazole
- D. Iodine
Correct Answer: A
Rationale: β-Adrenergic blockers work rapidly to decrease the cardiovascular manifestations of thyroid storm. The other medications take days to weeks to have an impact on thyroid function.
The nurse is admitting a patient with possible syndrome of inappropriate antidiuretic hormone (SIADH) due to a head trauma. Which of the following information obtained by the nurse is most important to communicate rapidly to the health care provider?
- A. The patient complains of dyspnea with activity.
- B. The patient has a urine specific gravity of 1.025.
- C. The patient has a recent weight gain of 5.6 kg.
- D. The patient has a serum sodium level of 119 mmol/L.
Correct Answer: D
Rationale: A serum sodium of less than 120 mmol/L increases the risk for complications such as seizures and needs rapid correction. The other data are not unusual for a patient with SIADH and do not indicate the need for rapid action.
The nurse is caring for a patient with primary hyperparathyroidism who has a serum calcium level of 3.5 mmol/L and a phosphorus of 0.5 mmol/L. Which of the following nursing actions should the nurse include in the plan of care?
- A. Institute routine seizure precautions.
- B. Monitor for positive Chvostek's sign.
- C. Encourage the patient to remain on bed rest.
- D. Encourage 3000-4000 mL of oral fluids daily.
Correct Answer: D
Rationale: The patient with hypercalcemia is at risk for kidney stones, which may be prevented by a high fluid intake. Seizure precautions and monitoring for Chvostek's or Trousseau's sign are appropriate for hypocalcemic patients. The patient should engage in weight-bearing exercise to decrease calcium loss from bone.