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 C
Explanation
A. Incorrect. This statement describes the cause of diabetes mellitus, not Addison's disease.
B. Incorrect. Overproduction of growth hormone is associated with conditions like acromegaly or gigantism, not Addison's disease.
C. Correct. Addison's disease is caused by the lack of production of aldosterone by the adrenal gland.
D. Incorrect. Overproduction of parathormone is associated with hyperparathyroidism, not Addison's disease.
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