The nurse has reviewed the Nurses' Notes and Vital Signs at 0900.

Complete the following sentence by using the lists of options.

The client is most at risk for

due to

.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

seizures: If a thyroid storm occurs, the client can experience seizures due to the extreme metabolic disturbances and nervous system overstimulation it causes. Seizures would be a serious complication indicating worsening neurological function. Therefore, the client’s risk for seizures is directly related to the risk of developing a thyroid storm after surgery.
paralytic ileus: Paralytic ileus involves bowel inactivity post-surgery, but the client had normoactive bowel sounds before surgery and no current documentation of absent or significantly reduced bowel activity. Therefore, this is not the most immediate risk based on current findings.
pneumonia: The client is receiving oxygen therapy and has a slightly increased respiratory rate after surgery, but no signs of labored breathing, abnormal lung sounds, or infection are reported. Although inactivity can contribute to pneumonia risk postoperatively, there are no current findings indicating that pneumonia is developing right now.
thyroid storm: The client had a thyroidectomy after presenting with signs of severe hyperthyroidism (weight loss, heat intolerance, anxiety, exophthalmos, goiter) and elevated T3 and T4 levels. Thyroid storm is a critical risk after thyroidectomy due to sudden hormone release, and it can cause life-threatening complications such as high fever, hypertension, tachycardia, and altered mental status.
bowel sounds: The bowel sounds were normal before surgery, and there is no mention of significant gastrointestinal changes postoperatively. Bowel sounds alone are not the critical factor leading to the client’s highest current risk.
inactivity: The client is currently lethargic after surgery and under the effects of anesthesia, which reduces movement and activity. Inactivity can cause decreased lung expansion and increase the risk of pulmonary complications like pneumonia. Although this is a concern, inactivity is not the client's most critical immediate risk compared to thyroid storm.

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Correct Answer is C

Explanation

A. "Your baby needs to suck on a pacifier.": While non-nutritive sucking on a pacifier can sometimes soothe a fussy baby, it is not the first recommendation, especially for a newborn who is establishing breastfeeding. Early introduction of pacifiers can interfere with successful breastfeeding due to nipple confusion.

B. "Breastfed babies are usually fussy from swallowing too much air during feedings.": Although some air swallowing can occur, especially if the latch is poor, this is not typically the primary reason for persistent crying. Addressing crying with soothing techniques like swaddling is a more immediate and supportive intervention for the parent.

C. "Swaddling your baby snugly in a blanket might help soothe her.": Swaddling provides warmth, security, and a sense of being back in the womb, which can calm a newborn effectively. It reduces the startle reflex and helps regulate the baby's nervous system, often resulting in decreased crying and improved comfort.

D. "Breastfed babies often need to be supplemented with formula.": Routine supplementation with formula is not recommended for healthy breastfed newborns unless there are clear medical indications. Promoting exclusive breastfeeding supports optimal nutrition, bonding, and gut health in the early postpartum period.

A. Provide the client with low-calorie formula B. Increase the rate of the client's feeding C. Switch the client to a formula containing less protein D. Administer the client's formula at room temperature.

Correct Answer is D

Explanation

A. Provide the client with low-calorie formula: The calorie content of the formula is not typically responsible for diarrhea. Diarrhea is more often related to formula intolerance, contamination, or rapid feeding rates rather than calorie density.

B. Increase the rate of the client's feeding: Increasing the rate can worsen diarrhea by overwhelming the gastrointestinal system, leading to poor absorption and increased fluid loss. Slower rates are often needed if diarrhea occurs.

C. Switch the client to a formula containing less protein: Protein content is usually not the cause of diarrhea. Specialized formulas may be needed for certain conditions, but protein itself is not typically a trigger for diarrhea.

D. Administer the client's formula at room temperature: Cold formula can cause gastric cramping and diarrhea. Administering the formula at room temperature helps reduce gastrointestinal irritation and promotes better tolerance of the feeding.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3°C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Complete the following sentence by using the lists of options. The client is most at risk for ________ due to ________.

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A nurse is assisting in the care of a client who is 48 hr postpartum. The client states, "My baby won't stop crying even though I've changed her diaper and breastfed her." Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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The nurse has reviewed the Nurses' Notes and Vital Signs at 0900.

Complete the following sentence by using the lists of options.

The client is most at risk for

due to

.