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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A: Purple striations. These are also known as striae, and they are caused by the thinning and weakening of the skin and underlying connective tissue due to cortisol. They appear as purple or red lines on the abdomen, thighs, breasts, or arms.
Choice C: Buffalo hump. This is a term used to describe the accumulation of fat on the upper back and neck due to cortisol. It gives the appearance of a hump or a rounded shape.
Choice E: Moon face. This is a term used to describe the rounding and fullness of the face due to cortisol. It gives the
appearance of a moon-like shape.
Choice B: Tremors. These are not a clinical manifestation of Cushing’s syndrome, but rather a sign of hyperthyroidism, which is a condition caused by excess thyroid hormone production or exposure. Thyroid hormone affects the nervous system and causes increased muscle activity and tremors.
Choice D: Obese extremities. These are not a clinical manifestation of Cushing’s syndrome, but rather a sign of hypothyroidism, which is a condition caused by low thyroid hormone production or exposure. Thyroid hormone affects the metabolism of carbohydrates, proteins, and fats, and causes decreased energy expenditure and weight gain.
Correct Answer is B
Explanation
Choice A: Upper left quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper left quadrant of the abdomen contains organs such as the stomach, spleen, pancreas, and part of the colon. Abdominal pain in this area can indicate conditions such as gastritis, peptic ulcer, pancreatitis, splenomegaly, or colon cancer.
Choice B: Lower left quadrant. This is the location where the nurse should expect the client to report abdominal pain who has diverticular disease, which is a condition that involves the formation of pouches or sacs in the wall of the colon. These pouches or sacs are called diverticula, and they can become inflamed or infected, causing diverticulitis. Diverticulitis can cause abdominal pain, fever, nausea, vomiting, and changes in bowel habits. The most common site of diverticula formation and diverticulitis is the sigmoid colon, which is located in the lower left quadrant of the abdomen.
Choice C: Upper right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The upper right quadrant of the abdomen contains organs such as the liver, gallbladder, duodenum, and part of the colon. Abdominal pain in this area can indicate conditions such as hepatitis, cholecystitis, duodenal ulcer, or colon cancer.
Choice D: Lower right quadrant. This is not the location where the nurse should expect the client to report abdominal pain who has diverticular disease. The lower right quadrant of the abdomen contains organs such as the appendix, cecum, and part of the colon. Abdominal pain in this area can indicate conditions such as appendicitis, Crohn’s disease, or colon cancer.
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