A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?
Neck stiffness
Hoarseness
Moderate serosanguineous drainage
Muscle twitching
The Correct Answer is D
Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm.
A. Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B. Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C. Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D. Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.
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Related Questions
Correct Answer is D
Explanation
D. NPO status is typically implemented in the initial management of acute pancreatitis to rest the pancreas and reduce pancreatic enzyme secretion, which can exacerbate inflammation and tissue damage. Nutritional support may be gradually reintroduced once the client's condition stabilizes and symptoms improve.
A. Placing the client in a supine position is not recommended for acute pancreatitis because it can exacerbate pain and discomfort.
B. The priority in acute pancreatitis is to address pain, manage complications such as fluid imbalances or infections, and support pancreatic rest.
C. Hypercalcemia can occur as a complication of acute pancreatitis due to calcium mobilization from damaged pancreatic cells. However, keeping the client NPO is priority.
Correct Answer is D
Explanation
D. Respite care services provide temporary relief and support for caregivers by offering short-term care for their loved ones. This allows caregivers to take a break, attend to their own needs, and prevent burnout. Recommending respite care services is a proactive approach to addressing the caregiver's exhaustion and ensuring the well-being of both the caregiver and the client with Alzheimer's disease.
A. The caregiver's exhaustion and irritability may be due to the stress of caregiving rather than intentional neglect or abuse.
B. Relying on medication to manage stress and sleep may not be the best long-term solution and can potentially lead to dependence or other adverse effects.
C. Contacting hospice services for end-of-life care is not appropriate for a client with moderate Alzheimer's disease unless the client's condition has progressed to a terminal stage. Hospice care focuses on providing comfort and support for individuals with a terminal illness who have a life expectancy of six months or less.
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