Nokea
The nurse is caring for a client post-thyroidectomy. Which finding indicates a potential complication?
- A. Hoarseness
- B. Incisional pain
- C. Mild swelling at the site
- D. Thirst
Correct Answer: A
Rationale: Hoarseness post-thyroidectomy may indicate recurrent laryngeal nerve damage, a serious complication requiring immediate reporting.
You may also like to solve these questions
A client with a diagnosis of gout is prescribed indomethacin. The nurse should instruct the client to:
- A. Take the medication with food to reduce stomach upset.
- B. Avoid drinking alcohol.
- C. Limit fluid intake.
- D. Take the medication at bedtime only.
Correct Answer: A,B
Rationale: Taking indomethacin with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.
Select the complication of intravenous therapy that is accurately paired with one of its interventions.
- A. Infection: Lowering the limb to promote circulation
- B. Infiltration: The application of cold to the site
- C. Extravasation: The aspiration of contents including blood from the IV cannula
- D. Hematoma: The administration of dexrazoxane
Correct Answer: C
Rationale: Aspirating contents from the IV cannula is an intervention for extravasation to remove vesicant drugs and minimize tissue damage.
A client has received a dose of dimenhydrinate. The nurse determines that the medication is effective when the client obtains relief of which problem?
- A. Chills
- B. Headache
- C. Ringing in the ears
- D. Nausea and vomiting
Correct Answer: D
Rationale: Dimenhydrinate is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. None of the other options are associated with the described symptoms.
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
- A. Accepting the client while not arguing with the delusion.
- B. Focusing on the feelings or meaning of the delusion.
- C. Focusing on events and topics based in reality.
- D. Confronting the client's beliefs.
- E. Interacting with the client only when he is based in reality.
Correct Answer: A,B,C
Rationale: To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.
A diabetic primigravid client at 38 weeks' gestation asks the nurse why she had a fetal acoustic stimulation during her last nonstress test. Which of the following should the nurse include as the rationale for this test?
- A. To listen to the fetal heart rate
- B. To startle and awaken the fetus
- C. To stimulate mild contractions
- D. To confirm amniotic fluid amount
Correct Answer: B
Rationale: Fetal acoustic stimulation is used to startle and awaken the fetus, prompting movement to assess fetal heart rate reactivity during a nonstress test. It does not directly measure heart rate, stimulate contractions, or assess amniotic fluid.