A nurse is monitoring a client following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypoparathyroidism?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss
The Correct Answer is B
Choice A reason: This is an incorrect finding, because elevated blood pressure is not a sign of hypoparathyroidism, which is a condition that occurs when the parathyroid glands produce insufficient parathyroid hormone (PTH). PTH regulates the calcium and phosphorus levels in the blood and bones. Elevated blood pressure can be a sign of hyperparathyroidism, which is the opposite condition.
Choice B reason: This is the correct finding, because involuntary muscle spasms are a sign of hypoparathyroidism, which causes hypocalcemia, or low blood calcium levels. Hypocalcemia can cause neuromuscular irritability and tetany, which are manifested by muscle spasms, twitching, cramps, or seizures.
Choice C reason: This is an incorrect finding, because cold intolerance is not a sign of hypoparathyroidism, but a sign of hypothyroidism, which is a condition that occurs when the thyroid gland produces insufficient thyroid hormone. Thyroid hormone regulates the metabolism and body temperature. Cold intolerance can also be a sign of Hashimoto's thyroiditis, which is an autoimmune disease that causes inflammation and destruction of the thyroid gland.
Choice D reason: This is an incorrect finding, because weight loss is not a sign of hypoparathyroidism, but a sign of hyperthyroidism, which is a condition that occurs when the thyroid gland produces excessive thyroid hormone. Thyroid hormone increases the metabolism and energy expenditure. Weight loss can also be a sign of Graves' disease, which is an autoimmune disease that causes overstimulation and enlargement of the thyroid gland.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.
Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.
Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.
Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.
Correct Answer is B
Explanation
Choice A reason: Maintaining the client's head of the bed at 20% is an incorrect action, because the head of the bed should be elevated at least 30% to prevent aspiration of the feeding.
Choice B reason: Monitoring the client’s blood glucose level is a correct action, because enteral feedings can affect the blood glucose level and the client may need insulin adjustments.
Choice C reason: Flushing the enteral feeding tube with 10 mL of cool water after each medication is an incorrect action, because cool water can cause cramping and nausea. The nurse should use warm water to flush the tube and use at least 30 mL of water to prevent clogging.
Choice D reason: Obtaining an x-ray after beginning the feeding is an incorrect action, because an x-ray should be obtained before starting the feeding to confirm the placement of the tube.
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