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 the highest risk for developing hypocalcemia evidenced by the

A is incorrect because the client should stand with their feet together, not 1 foot apart, for the Romberg test.

B is incorrect because the client should hold their arms at their sides, not on their hips, for the Romberg test.

C is incorrect because the nurse should stand close to the client, not across the room, to prevent injury in case of a fall.

D is correct because the Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.

The correct answer is D

Choice A Reason: While croup can be serious, an O2 saturation of 92% on room air is generally stable. This child's condition is concerning but not immediately life-threatening.

Choice B Reason: A 15-year-old adolescent who is 2 hours postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication is in need of comfort measures. Postoperative pain management is important for recovery, but it is not a priority over more critical conditions.

Choice C Reason: A 3-year-old toddler with gastroenteritis, moderate dehydration, and two loose bowel movements over the past 24 hours requires rehydration and monitoring. The normal range for bowel movements varies, but two loose stools in 24 hours for a toddler with gastroenteritis is not unusual. Dehydration can become severe, so this child should be assessed soon, but it is not the most urgent case.

Choice D Reason: This child's sudden relief from pain could be a sign of a perforated appendix, a serious complication that requires immediate medical attention. Therefore, this child's condition is the most urgent and requires immediate assessment.