A nurse is caring for a client who is 1 day postoperative following a total thyroidectomy.

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

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evidenced by the

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.

A. Heart rate 136/min is a normal finding for a newborn. The normal range of heart rate for a newborn is 100 to 160/min.

B. Nasal flaring is an abnormal finding for a newborn. Nasal flaring indicates respiratory distress and may be caused by conditions such as pneumonia, meconium aspiration, or congenital heart defects.

C. Transient strabismus is a normal finding for a newborn. Transient strabismus is a temporary misalignment of the eyes that occurs due to weak eye muscles and poor coordination. It usually resolves by 3 to 6 months of age.

D. Overlapping of sutures is a normal finding for a newborn. Overlapping of sutures is caused by molding of the skull during delivery and allows the head to fit through the birth canal. It usually resolves within a few days after birth.

• Anti-Glycan Neu5Gc Antibodies (AGNA) are antibodies that recognize a carbohydrate antigen called N- glycolylneuraminic acid (Neu5Gc), which is found in animal-derived foods and tissues, but not in humans. Humans can incorporate Neu5Gc from their diet into their own cells, which can trigger an immune response and the production of AGNA.
• AGNA have been associated with various inflammatory and autoimmune diseases, such as atherosclerosis, rheumatoid arthritis, Crohn's disease, and cancer. AGNA may also play a role in the rejection of bioprosthetic heart valves, which are made from animal tissues that contain Neu5Gc.
• A client with carcinoma in situ of the left breast is a client with a non-invasive form of breast cancer, where the abnormal cells are confined to the ducts or lobules of the breast. This type of cancer has a high chance of cure with surgery and/or radiation therapy.
• Increased levels of AGNA in a client with carcinoma in situ of the left breast may indicate that the client has an increased risk of inflammation and infection, as AGNA can activate the complement system and recruit inflammatory cells to the site of Neu5Gc expression. This may impair the healing process and increase the chances of complications after surgery or radiation therapy.

Therefore, the practical nurse (PN) should anticipate that the client's plan of care will include initiation of changes in infection control measures, such as prophylactic antibiotics, wound care, sterile dressing changes, and monitoring for signs and symptoms of infection (such as fever, redness, swelling, pain, or pus). These measures will help to prevent or treat any potential infection and promote wound healing.

Therefore, option A is the correct answer, while options B, C, and D are incorrect.

Option B is incorrect because increasing the client's dietary servings of fruits and vegetables may not have a significant impact on the levels of AGNA or Neu5Gc in the client's body.

Option C is incorrect because limiting the client's fluid intake to avoid hemodilution may not be necessary or beneficial for the client's condition.

Option D is incorrect because avoiding the client's exposure to cold temperatures may not be relevant or helpful for the client's condition.