A nurse is caring for a client on a medical-surgical unit.
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. Click to highlight the findings below that the nurse should report to the provider.
Nurses Notes
Oxygen saturation 95%
The client's voice is hoarse.
The client reports tingling around the mouth
Moderate serosanguinous drainage noted on neck dressing.
The client has a slight tremor noted in both hands.
The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
The client appears restless
The client's voice is hoarse.
The client reports tingling around the mouth
Moderate serosanguinous drainage noted on neck dressing.
The client has a slight tremor noted in both hands.
The client's temperature has increased in 1 hr from 375° C (99.5° F) to 38.6°C (101.5 F)
The client appears restless
Oxygen saturation 95%
The Correct Answer is ["A","B","C","D","E","F"]
The nurse should report the hoarseness of the client's voice, which could indicate recurrent laryngeal nerve damage, which is a risk associated with thyroid surgery. Tingling around the mouth may suggest hypocalcemia, a common complication after thyroidectomy due to accidental removal or damage to the parathyroid glands. The moderate serosanguinous drainage on the neck dressing could signify bleeding or infection, which requires immediate attention. The noted tremor in both hands and the increase in temperature could be signs of a thyroid storm, a rare but life-threatening condition.
Furthermore, the client's restlessness could be a response to discomfort or could indicate a more serious issue, such as an impending thyrotoxic crisis. Oxygen saturation at 95% is within normal limits postoperatively; however, it should be monitored closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sudden weight gain is a common sign of fluid overload in clients with end-stage kidney disease undergoing hemodialysis.
B. Skin turgor assessment is not as reliable in individuals with kidney disease due to changes in skin elasticity.
C. Flattened neck veins are not indicative of fluid overload; rather, they suggest dehydration.
D. Oxygen saturation may be affected by various factors but is not directly related to fluid overload in this context.
Correct Answer is B
Explanation
A. Administering corticosteroids is crucial during an Addisonian crisis but typically involves intravenous corticosteroids (not oral) during the crisis to quickly restore hormone levels. Oral corticosteroids are part of regular maintenance therapy but not an immediate intervention in the crisis.
B. Weighing the client daily is important to monitor for potential fluid loss, dehydration, or weight changes related to Addison's disease and Addisonian crisis. Clients with Addison’s disease may experience fluid and electrolyte imbalances, so daily weight tracking helps detect early signs of fluid shifts, which are critical in crisis prevention and management.
C. A low-carbohydrate diet is not recommended for clients with Addison’s disease, as they may need a balanced diet with sufficient carbohydrates to prevent hypoglycemia.
D. Fluid intake should not be restricted; rather, maintaining adequate hydration is vital. Clients in Addisonian crisis are often at risk for dehydration due to fluid losses and low aldosterone levels, making fluid replacement essential.
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