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. While a yearly dilated eye examination is crucial for the early detection and management of diabetic retinopathy, this action alone only addresses one of the two complications mentioned in the prompt. It does not prevent the development of nephropathy.
B. Examining the feet carefully every day is a vital preventive measure for diabetic neuropathy and peripheral vascular disease to avoid foot ulcers and infections. However, daily foot checks do not prevent microvascular damage to the eyes or kidneys.
C. Compression stockings are used to manage venous insufficiency or peripheral edema, but they are not standard preventative therapy for diabetic retinopathy or nephropathy, and tight hosiery may even be contraindicated if the client has co-existing peripheral arterial disease.
D. Maintaining stable, optimal blood glucose levels is the most effective primary intervention to prevent both retinopathy and nephropathy. Chronic hyperglycemia causes microvascular damage to the small blood vessels in both the retina and the renal glomeruli; therefore, strict glycemic control slows the onset and progression of both conditions simultaneously.
Correct Answer is B
Explanation
A. Semi-Fowler's with neck extended: Keeping the neck extended can put strain on the surgical incision site, increasing the risk of complications. It's important to avoid excessive neck movement.
B. Semi-Fowler's with neck in a neutral position: This position is optimal for clients post-thyroidectomy. It helps reduce swelling and pressure on the surgical site while maintaining the neck in a neutral and supported position.
C. High Fowler's with neck extended: A high Fowler's position with the neck extended may increase the risk of strain on the surgical incision and should be avoided.
D. High Fowler's with the neck in a neutral position: While a high Fowler's position can be comfortable for the client, it's important to ensure that the neck is in a neutral position to minimize strain on the surgical incision.
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