A nurse is assisting with the plan of care for a client who is 4 hr postoperative from a subtotal thyroidectomy. Which of the following implementations should the nurse recommend?
Check for bleeding on the dressing at the back of the client’s neck.
Ensure that acetylcysteine IV is readily available.
Place the client in a side-lying position.
Check the client for asterixis.
The Correct Answer is A
Choice A: Check for bleeding on the dressing at the back of the client’s neck. This is an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy, which is a surgical removal of part of the thyroid gland. The nurse should check for bleeding on the dressing at the back of the client’s neck because this is where blood can pool and go unnoticed. Bleeding can cause hematoma, compression of the airway, and respiratory distress.
Choice B: Ensure that acetylcysteine IV is readily available. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Acetylcysteine IV is an antidote for acetaminophen overdose, which can cause liver damage, but it is not related to thyroid surgery.
Choice C: Place the client in a side-lying position. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. The nurse should place the client in a semi-Fowler’s position, which is a position with the head of the bed elevated to 30 to 45 degrees. This position can facilitate breathing, reduce edema, and prevent aspiration.
Choice D: Check the client for asterixis. This is not an implementation that the nurse should recommend for a client who is 4 hr postoperative from a subtotal thyroidectomy. Asterixis is a sign of hepatic encephalopathy, which is a condition caused by liver failure, but it is not related to thyroid surgery.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A: Sedentary lifestyle. This is a risk factor for developing type 2 diabetes mellitus, which is a condition that occurs when the body becomes resistant to the action of insulin or does not produce enough insulin to maintain normal blood glucose levels. Insulin is a hormone that helps glucose enter the cells and be used for energy. A sedentary lifestyle can increase the risk of type 2 diabetes mellitus by reducing physical activity, which can improve insulin sensitivity and lower blood glucose levels.
Choice B: Triglyceride level of 100 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Triglycerides are a type of fat that circulates in the blood and can be used for energy or stored in adipose tissue. A high triglyceride level can indicate an increased risk of cardiovascular disease, but it is not directly related to type 2 diabetes mellitus.
Choice C: Blood glucose of 98 mg/dL. This is not a risk factor for developing type 2 diabetes mellitus, but rather a normal value. Blood glucose is the amount of glucose in the blood, which can vary depending on food intake, physical activity, and hormonal regulation. A high blood glucose level can indicate type 2 diabetes mellitus, but it is not a cause of it.
Choice D: Recent viral infection. This is not a risk factor for developing type 2 diabetes mellitus, but rather a possible trigger for type 1 diabetes mellitus, which is a condition that occurs when the immune system destroys the beta cells of the pancreas that produce insulin. A viral infection can trigger an autoimmune response that attacks the beta cells and causes type 1 diabetes mellitus.
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