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The nurse has reviewed the Nurses' Notes and Vital Signs at 1200.

Which of the following 2 findings indicate that the client is experiencing a complication after the procedure?

Hoarseness

Drainage

Sensation

Vital signs

Pain assessment

Answer and Explanation

Correct Answer : C,D

Hoarseness: Mild hoarseness is a common temporary effect after thyroid surgery due to irritation or swelling near the recurrent laryngeal nerve. While it needs monitoring, slight hoarseness alone is not necessarily a sign of a serious complication if it is not worsening or associated with airway compromise.
Drainage: A moderate amount of serosanguineous drainage from the incision site is expected after surgery. Although the drainage should continue to be monitored for increase or color change, the amount described here is not immediately concerning for a postoperative complication.
Sensation: The client reports tingling in the fingers, which suggests hypocalcemia due to accidental removal or damage to the parathyroid glands during surgery. Hypocalcemia is a serious complication of thyroidectomy that can progress to muscle cramps, tetany, and seizures if untreated.
Vital signs: The client’s rising temperature, tachycardia, hypertension, and increased respiratory rate are concerning for a developing thyroid storm, a rare but life-threatening complication after thyroid surgery. These vital signs warrant immediate intervention to prevent rapid deterioration.
Pain assessment: A pain score of 3 out of 10 is mild and expected following surgery. This level of discomfort is manageable and not indicative of a major complication, provided it does not rapidly escalate or localize severely around the surgical site.

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Correct Answer is A

Explanation

A. Monitor the client for 1 hr after meals: Clients with anorexia nervosa are at high risk for purging behaviors such as vomiting or excessive exercise after meals. Monitoring them for at least 1 hour post-meal helps prevent these behaviors and supports the therapeutic goal of safe weight restoration.

B. Allow the client 2 hr to finish meals: Allowing 2 hours to complete meals is too long and may encourage food avoidance behaviors. Structured meal times with limits (usually around 30 to 45 minutes) are important to establish routine eating habits and prevent manipulation of eating times.

C. Weigh the client every 2 days: Clients with anorexia nervosa are typically weighed daily, often at the same time each morning, to closely monitor weight trends and assess the effectiveness of the treatment plan. Monitoring every 2 days may miss rapid changes that require immediate intervention.

D. Check the client's vital signs two times per week: Vital signs should be checked daily in clients with anorexia nervosa, especially early in treatment, because of the risks of bradycardia, hypotension, and hypothermia. Infrequent monitoring can delay recognition of life-threatening physiological instability.

A. Repeat quantitative B-hCG level B. Methotrexate IM C. Blood typing D. Cervical cerclage E. Transvaginal ultrasound

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

• Repeat quantitative B-hCG level: Monitoring the trend of quantitative beta-hCG levels is crucial in suspected ectopic pregnancy. Falling or plateauing hCG levels confirm the diagnosis and guide the management plan, especially if methotrexate is administered or surgical intervention is considered.

• Methotrexate IM: Methotrexate is an anticipated prescription for the medical management of a stable ectopic pregnancy. It works by stopping the growth of rapidly dividing cells and is appropriate when the client is hemodynamically stable and the ectopic pregnancy is unruptured.

• Blood typing: Blood typing is essential to determine Rh factor status. If the client is Rh-negative, Rh immune globulin should be administered to prevent isoimmunization, which could impact future pregnancies. This is a standard part of the care plan for any pregnancy loss or threatened pregnancy complication.

• Transvaginal ultrasound: A transvaginal ultrasound is needed to confirm the location of the pregnancy. In ectopic pregnancies, it helps visualize the presence or absence of an intrauterine gestational sac and may directly identify ectopic implantation, such as in the fallopian tube.

• Cervical cerclage: Cervical cerclage is contraindicated in this case. It is used to prevent preterm birth in clients with cervical insufficiency but is not appropriate in a non-viable pregnancy or suspected ectopic pregnancy. Placing a cerclage could worsen the clinical situation and delay necessary treatment.

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The nurse has reviewed the Nurses' Notes and Vital Signs at 1200. Which of the following 2 findings indicate that the client is experiencing a complication after the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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The nurse has reviewed the Nurses' Notes and Vital Signs at 1200.

Which of the following 2 findings indicate that the client is experiencing a complication after the procedure?