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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Tachycardia - This is an increased heart rate, which can occur in response to low blood sugar levels.
B. Moist clammy skin - Sweating and clamminess are common symptoms of hypoglycemia.
C. Polydipsia - This is excessive thirst, which is not typically a manifestation of hypoglycemia. It is more commonly associated with hyperglycemia (high blood sugar levels).
D. Blurred vision - This can occur when the eyes are not receiving enough glucose due to low blood sugar levels.
E. Polyuria - This is excessive urination, which is not typically a manifestation of hypoglycemia. It is more commonly associated with hyperglycemia.
Correct Answer is ["A","B","C","E"]
Explanation
A. Take thyroid replacement medication, as ordered. This is crucial for individuals who have undergone a thyroidectomy, as they will likely need thyroid hormone replacement therapy to maintain normal thyroid function.
B. Watch for changes in body functioning, such as lethargy, restlessness, sensitivity to cold, and dry skin. Report them to the physician.
These symptoms could indicate potential issues with thyroid hormone levels and should be reported to the physician for further evaluation.
C. Recognize the signs of dehydration. This is important for overall health and can be especially relevant post-surgery. Dehydration can exacerbate other issues and slow down the healing process.
D. Carry injectable dexamethasone at all times. This is not a standard discharge instruction after a thyroidectomy. Dexamethasone may be prescribed for specific situations, but it is not a routine medication for all patients post-thyroidectomy.
E. Report any signs and symptoms of hypoglycemia. This is important because thyroidectomy can affect blood sugar levels. Monitoring for signs of hypoglycemia is crucial for the client's well-being.
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