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 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.
Correct Answer is C
Explanation
A. Flaccid muscles are associated with conditions like hypokalemia, not hypoparathyroidism. In hypoparathyroidism, there is a deficiency of parathyroid hormone (PTH), which leads to low calcium levels and can result in muscle spasms and tetany, not flaccid muscles.
B. While anorexia can occur in clients with various health conditions, it is not a specific finding associated with hypoparathyroidism.
C. Correct. Hypoparathyroidism is characterized by low levels of parathyroid hormone (PTH), which leads to low calcium levels in the blood. This can cause symptoms such as numbness, tingling, and muscle cramps, especially in the extremities.
D. A positive Chvostek's sign is associated with hypocalcemia, which can be caused by hypoparathyroidism. Therefore, a negative Chvostek's sign would not be an expected finding in a client with hypoparathyroidism.
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