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.

Rationale:

• Administer aspirin for fever: Aspirin can increase circulating thyroid hormones by displacing T4 and T3 from protein-binding sites. In a hyperthyroid or recently post-thyroidectomy patient, this may precipitate or worsen a thyroid storm. Acetaminophen is a safer antipyretic choice.

• Apply cooling blanket: The client’s postoperative fever (38.3°C), elevated heart rate (98/min), and history of hyperthyroidism indicate a risk for thyroid storm. External cooling is a supportive measure to manage hyperthermia during this critical period.

• Monitor vital signs every 4 hours: This is anticipated to detect signs of complications such as thyroid storm, hemorrhage, or airway compromise. Postoperative clients require close observation to identify early changes in temperature, pulse, or respiration.

• Place client on telemetry: Cardiac monitoring is essential after thyroidectomy in clients with a history of hyperthyroidism. Increased metabolic demand, fever, and potential for arrhythmias justify continuous cardiac observation.

• Palpate thyroid area to assess for hematoma: A neck hematoma is a potentially life-threatening complication of thyroid surgery. It can lead to airway obstruction. Palpation and inspection for swelling or firmness around the incision site are critical nursing assessments.

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.