The nurse is performing an assessment of the thyroid gland. In order to decrease the risk that the nurse will stimulate the release of large amounts of thyroid hormone, what should the nurse be sure to do?
Palpate gently without repeated attempts.
Not palpate the thyroid and just listen for a bruit.
Palpate firmly in order to feel the thyroid gland.
Continue to palpate the gland until it is felt for enlargement.
The Correct Answer is A
Palpate gently without repeated attempts. Palpating the thyroid gland can stimulate the release of thyroid hormone, which can result in a thyroid storm, a potentially life-threatening condition characterized by a rapid heart rate, fever, and high blood pressure. Therefore, the nurse should be careful not to overstimulate the thyroid gland.
Not palpating the thyroid and just listening for a bruit (B) is not a sufficient assessment of the thyroid gland. Palpating the gland firmly in order to feel it for enlargement (C) can be too stimulating and increase the risk of thyroid hormone release. Continuing to palpate the gland until it is felt for enlargement (D) is not necessary and may result in overstimulation of the gland.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Diarrhea. A client who is recovering from bariatric surgery and is eating from a portable commode is at risk for diarrhea. Diarrhea can cause fluid and electrolyte imbalances, leading to dehydration, which can be life-threatening, especially in the immediate postoperative period.
Option A, impaired mobility, would not be a priority concern in the immediate postoperative period for this client.
Option B, impaired gas exchange, is not related to the situation.
Option C, self-care deficit, maybe a concern but is not as significant as diarrhea in the immediate postoperative period.
Correct Answer is B
Explanation
Impaired Gas Exchange. Impaired gas exchange is the greatest concern in the immediate postoperative period for a client recovering from bariatric surgery, as the client may have difficulty breathing due to anesthesia, pain medication, or obesity-related respiratory problems.
Option A, Impaired Mobility, is a concern but not the greatest concern in the immediate postoperative period.
Option C, Self-Care Deficit, may be an issue but is not the greatest concern in the immediate postoperative period.
Option D, Diarrhea, may occur after bariatric surgery but is not the greatest concern in the immediate postoperative period.
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