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.
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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Related Questions
Correct Answer is D
Explanation
A. Incorrect. Palpitations, which are rapid or irregular heartbeats, are more commonly associated with hyperthyroidism, where there is an excess of thyroid hormones.
B. Incorrect. Diaphoresis, or excessive sweating, is not typically associated with hypothyroidism.
C. Incorrect. Exophthalmos, or bulging of the eyes, is a characteristic finding in hyperthyroidism (specifically Graves' disease) and is not typically seen in hypothyroidism.
D. Correct. Weight gain is a common finding in hypothyroidism. The slowing down of metabolic processes due to insufficient thyroid hormones can lead to an increase in body weight.
Correct Answer is ["A","C","D","E"]
Explanation
A: Hepatomegaly is a common manifestation of acromegaly, as excess growth hormone can cause organ enlargement.
B: Moon face is associated with Cushing's syndrome, not acromegaly. In acromegaly, facial changes are characterized by bony enlargement and coarsening of features, not the rounded face seen in Cushing's syndrome.
C: Coarse facial features are a classic sign of acromegaly due to the overgrowth of facial bones and soft tissue, leading to prominent brows, a larger nose, and a protruding jaw.
D: Enlarged distal extremities, such as hands and feet, are typical in acromegaly because of excessive growth hormone, which affects the growth plates in the bones and causes an increase in size and thickness.
E: This can occur due to optic nerve involvement, which is associated with pituitary tumors that can cause acromegaly. Vision changes, including loss of color discrimination, may be noted as a result of pressure on the optic chiasm.
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