The nurse has reviewed the Vital Signs at 1000.

Exhibits
Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

"Use sunglasses if your eyes are sensitive to light."

"Continue eating foods with protein."

"Remain on bedrest for 3 to 5 days following discharge."

"You need to support your neck when coughing or moving."

"You will no longer need to take any medications for your thyroid now that you have had surgery."

Answer and Explanation

Correct Answer : A,B,D

Rationale:

• "Use sunglasses if your eyes are sensitive to light." Exophthalmos from Graves' disease can persist even after thyroidectomy. Sunglasses help reduce photophobia and protect protruding eyes from dryness and injury.

• "Continue eating foods with protein." Protein is essential for wound healing and energy. Postoperative hypermetabolic states can also increase protein needs, so adequate intake supports recovery.

• "You need to support your neck when coughing or moving." Neck support prevents strain on the surgical site and reduces the risk of wound dehiscence or hematoma formation during activities that increase intrathoracic pressure.

• "Remain on bedrest for 3 to 5 days following discharge." Prolonged bedrest is not recommended post-thyroidectomy. Early ambulation reduces risk of complications such as pneumonia and deep vein thrombosis and supports normal recovery.

• "You will no longer need to take any medications for your thyroid now that you have had surgery." Total or subtotal thyroidectomy often results in hypothyroidism, requiring lifelong thyroid hormone replacement (e.g., levothyroxine). Medication needs depend on the amount of thyroid tissue removed.

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Correct Answer is B

Explanation

Rationale:

A. Urinary retention: Urinary retention is a potential side effect of epidural anesthesia due to blockade of sacral nerves, not necessarily a sign of unrelieved pain. It may occur even if pain is well managed, especially with regional anesthetics affecting bladder function.

B. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain. When verbal reporting is limited or unreliable, restlessness may reflect discomfort, agitation, or anxiety related to inadequate pain control following procedures such as epidural administration.

C. Difficulty swallowing: Difficulty swallowing is not associated with pain from a herniated disc or the effects of an epidural. It may instead suggest upper airway or neurologic issues and should prompt assessment for complications unrelated to pain control.

D. Constipation: Constipation is more commonly linked to opioid use or immobility rather than unrelieved pain. While discomfort may contribute, constipation alone does not reliably indicate the adequacy of pain relief in clients receiving an epidural.

A. Deep palpation B. Light palpation C. Auscultation D. Inspection

Correct Answer is D,C,B,A

Explanation

Rationale:

D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.

C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.

B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.

A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.

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The nurse has reviewed the Vital Signs at 1000. Exhibits Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D,C,B,A

Explanation

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The nurse has reviewed the Vital Signs at 1000.

Exhibits
Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.