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 D

Explanation

Rationale:

A. Hypertension: Hypertension is not typically associated with an allergic reaction to vancomycin. Hypotension may occur in severe reactions like "red man syndrome," but elevated blood pressure is generally unrelated to allergic responses.

B. Headache: Headache is a possible side effect of many medications, including vancomycin, but it does not specifically indicate an allergic reaction. It is a nonspecific symptom and usually does not warrant discontinuation unless severe.

C. Tinnitus: Tinnitus is a sign of ototoxicity, a known adverse effect of vancomycin, especially with high doses or prolonged use. However, it is not indicative of an allergic reaction but rather toxicity affecting the auditory system.

D. Urticaria: Urticaria, or hives, is a classic manifestation of an allergic reaction involving histamine release causing itchy, raised, red skin lesions. Its presence during vancomycin administration signals hypersensitivity and requires immediate attention.

A. "You can apply counterpressure to your back with each position change." B. "You should change positions as little as possible." C. "You should use patterned-paced breathing when changing positions." D. "You can splint the incision with a pillow when changing positions."

Correct Answer is D

Explanation

Rationale:

A. "You can apply counterpressure to your back with each position change.": Counterpressure is commonly used during labor to relieve back pain caused by fetal positioning. It is not relevant for postoperative cesarean pain, which is abdominal.

B. "You should change positions as little as possible.": Limiting movement after surgery can increase the risk of complications such as pneumonia and venous thromboembolism. Frequent, supported movement is encouraged to promote recovery and circulation.

C. "You should use patterned-paced breathing when changing positions.": Patterned-paced breathing is typically used during labor for pain management. While breathing techniques may offer mild comfort, they do not provide adequate support for incisional pain during movement.

D. "You can splint the incision with a pillow when changing positions.": Splinting the incision with a pillow provides support to the abdominal muscles, helping reduce tension and pain during movement. This is a safe and effective nonpharmacological strategy for post-cesarean clients.

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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 D

Explanation

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Correct Answer is D

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.