A nurse is assisting with the care of a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?
Determine the client’s calcium level.
Give the client an oral potassium supplement.
Administer intravenous normal saline solution.
Monitor the client’s peripheral pulses.
The Correct Answer is A
Choice A: Determine the client’s calcium level. This is the priority action for the nurse to take because the client might have hypocalcemia, which is a low level of calcium in the blood. Hypocalcemia can occur after a thyroidectomy due to accidental removal or damage of the parathyroid glands, which regulate calcium levels. Hypocalcemia can cause muscle spasms, tetany, paresthesia, and seizures.
Choice B: Give the client an oral potassium supplement. This is not an appropriate action for the nurse to take because the client might have hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can also occur after a thyroidectomy due to damage to the adrenal glands, which regulate potassium levels. Hyperkalemia can cause muscle weakness, arrhythmias, and cardiac arrest.
Choice C: Administer intravenous normal saline solution. This is not a necessary action for the nurse to take because the client does not have signs of dehydration or fluid imbalance. Normal saline solution does not affect calcium or potassium levels.
Choice D: Monitor the client’s peripheral pulses. This is an important action for the nurse to take, but not the priority. The nurse should monitor the client’s peripheral pulses for signs of decreased perfusion or ischemia, which can result from hypocalcemia or hyperkalemia affecting the cardiac function. However, this should be done after determining the client’s calcium level and correcting it if needed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Rapid pulse. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia, which is a low level of glucose in the blood. Hypoglycemia can cause rapid pulse due to increased sympathetic nervous system activity and decreased cardiac output.
Choice B: Clammy skin. This is not a finding that indicates that the client is experiencing DKA, but rather a sign of hypoglycemia. Hypoglycemia can cause clammy skin due to increased sweating and vasoconstriction.
Choice C: Choice C: Confusion is commonly found in HHS rather than DKA.
Choice D: Polydipsia. This is a finding that indicates that the client is experiencing DKA due to the high level of glucose in the blood. Hyperglycemia in DKA can cause polydipsia, which is excessive thirst, due to osmotic diuresis and dehydration.
Correct Answer is C
Explanation
Choice A: Hypernatremia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypernatremia is a high level of sodium in the blood, which can be caused by dehydration, excessive sodium intake, or kidney dysfunction. It is not related to Addison’s disease or cortisol and aldosterone levels.
Choice B: Bradycardia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Bradycardia is a slow heart rate, which can be caused by vagal stimulation, medication side effects, or cardiac disorders. It is not related to Addison’s disease or cortisol and aldosterone levels.
Choice C: Hypotension. This is a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease, which is a condition that occurs when the adrenal glands do not produce enough cortisol and aldosterone. Cortisol is a hormone that regulates the metabolism of carbohydrates, proteins, and fats, and helps the body cope with stress. Aldosterone is a hormone that regulates the balance of sodium and potassium in the blood and fluid volume. Addison’s disease can cause hypotension, which is a low blood pressure, due to decreased aldosterone production and fluid loss.
Choice D: Hypokalemia. This is not a manifestation that the nurse should monitor for in a client who is postoperative and has a history of Addison’s disease. Hypokalemia is a low level of potassium in the blood, which can be caused by diuretics, vomiting, diarrhea, or alkalosis. It is not related to Addison’s disease or cortisol and aldosterone levels.
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