Nokea
Which intervention is most appropriate to add to the client's care plan to the use of the personal bleeding after a subtotal thyroidectomy?
- A. Observe for signs of hypovolemic shock.
- B. Assess for dampness at the back of the client's neck.
- C. Remove the dressing to directly inspect the wound.
- D. Weigh all gauze dressings before and after changing.
Correct Answer: B
Rationale: Assessing for dampness at the back of the neck detects bleeding that may pool behind the client.
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The nurse observes a colleague caring for the client who had a hypophysectomy via the transsphenoidal approach 12 hours ago. Which action would require the observing nurse to intervene?
- A. Elevates the head of the client's bed to 30 degrees
- B. Gathers supplies to replace the bloody nasal packing
- C. Moisturizes the client's oral mucous membranes
- D. Places a cold washcloth over the client's swollen eyes
Correct Answer: B
Rationale: Nasal packing is left in place for 3-4 days post-hypophysectomy and should not be changed without an HCP order.
To detect complications of surgery in the immediate postoperative period, which assessment component is most important for the nurse to monitor?
- A. Blood pressure
- B. Urine output
- C. Upperness
- D. Specific gravity
Correct Answer: A
Rationale: Blood pressure monitoring detects adrenal insufficiency or bleeding post-adrenalectomy.
A woman with hypothyroidism asks the nurse why the doctor told her she cannot have a sedative. The nurse's response is based on which of the following facts?
- A. Sedatives potentiate thyroid replacement medication.
- B. Clients with hypothyroidism have increased susceptibility to all sedative drugs.
- C. Sedatives will have a paradoxical effect on clients with hypothyroidism.
- D. Sedatives would cause fluid retention and hypernatremia.
Correct Answer: B
Rationale: Hypothyroidism increases sensitivity to sedatives, risking excessive sedation or respiratory depression.
Which signs and symptoms are most appropriate for the nurse to investigate when screening adults who have come to be used to assess the patient's disease?
- A. Diarrhea, anorexia, and weight gain
- B. Constipation, weight loss, and thirst
- C. Polycholia, polyemia, and polyplegia
- D. Polyuria, polydipsia, and polyphagia
Correct Answer: D
Rationale: Polyuria, polydipsia, and polyphagia are classic symptoms of diabetes mellitus.
The nurse is planning to address diabetic meal planning with the client recently diagnosed with type 1 DM. Which action should the nurse take first?
- A. Encourage use of non-nutritive sweeteners that contain no calories.
- B. Emphasize the importance of keeping regular mealtimes every day.
- C. Teach the client how to count the carbohydrates in meals and snacks.
- D. Ask the client to identify favorite foods and the client's usual mealtimes.
Correct Answer: D
Rationale: Asking about favorite foods and usual mealtimes is an assessment question used in obtaining a thorough diet history; the nurse should take this action first prior to beginning teaching.