A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Place the head of the client's bed in the flat position.

Instruct the client to deep breathe every 4 hr.

Hyperextend the client's neck.

Check the client's voice every 2 hr.

Answer and Explanation

The Correct Answer is D

- Choice A Rationale: Placing the head of the bed in the flat position is not recommended as it can increase the risk of airway obstruction and reduce venous drainage from the head, which is especially critical after thyroid surgery.
- Choice B Rationale: While deep breathing is important postoperatively, it is not specific to thyroidectomy care and should be done more frequently than every 4 hours to ensure adequate ventilation and prevent atelectasis.
- Choice C Rationale: Hyperextending the client's neck can be harmful post-thyroidectomy as it may put stress on the surgical site, potentially leading to dehiscence or damage to the area.
- Choice D Rationale: Checking the client's voice every 2 hours is essential after a thyroidectomy because vocal cord paralysis can be an indicator of recurrent laryngeal nerve damage, which is a potential complication of the surgery. Monitoring the voice allows for early detection and intervention.

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Correct Answer is C

Explanation

A. Photophobia is not typically associated with hypothyroidism. It can be a symptom of conditions affecting the eyes, such as certain infections or ocular disorders.

B. Exophthalmos is a protrusion of the eyeballs and is a characteristic symptom of hyperthyroidism (overactive thyroid), not hypothyroidism (underactive thyroid).

C. Correct. Lethargy is a common symptom of hypothyroidism. It is characterized by extreme tiredness, sluggishness, and lack of energy.

D. Goiter is an enlargement of the thyroid gland and can occur in both hyperthyroidism and hypothyroidism. However, it is not a direct symptom; it is a physical finding that can be associated with thyroid disorders.

A. Check the pedal pulses. B. Request prescription for a relaxant. C. Verify the most recent calcium level. D. Administer an oral potassium supplement.

Correct Answer is C

Explanation

A. Checking the pedal pulses is important for assessing circulation, but it may not directly address the cause of the muscle spasms. In this case, addressing the electrolyte imbalance is a higher priority.

B. Requesting a relaxant might provide temporary relief for muscle spasms, but it does not address the potential underlying cause. It's important to identify and treat the root issue.

C. Correct. Severe muscle spasms in a client post-thyroidectomy could indicate hypocalcemia, as the parathyroid glands, which regulate calcium levels, can be affected during the surgery. Verifying the most recent calcium level will help determine if this is the cause.

D. Administering an oral potassium supplement addresses a different electrolyte imbalance (hypokalemia), which is not typically associated with muscle spasms following a thyroidectomy. Calcium levels are more relevant in this context.

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A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

Explanation

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