While assessing a patient who has just arrived in the post-anesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains this data. Which is the most important to communicate to the surgeon?

The patient’s voice is weak and hoarse sounding.

The patient is complaining of a 7/10 incisional pain.

The patient’s cardiac monitor shows a heart rate of 112.

The patient is increasingly swelling at the neck.

Answer and Explanation

The Correct Answer is D

This is a critical finding that could indicate bleeding or compromised airway, both of which are potentially life-threatening complications following a thyroidectomy. Immediate intervention may be necessary to prevent further harm to the patient. The other options are important to note and should be addressed, but they do not require immediate intervention as the swelling in the neck does.

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Correct Answer is B

Explanation

The statement "I had the stomach ﬂu earlier this week and couldn't take the hydrocortisone" indicates that the patient may not be adhering to their prescribed medication regimen, which can lead to an Addisonian crisis. Therefore, the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition is appropriate.

Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Hydrocortisone is a glucocorticoid medication that is often used to replace the cortisol that the adrenal glands are not producing. In the Addisonian crisis, the body is unable to produce the necessary levels of cortisol and aldosterone, which can lead to potentially life-threatening complications such as hypotension, dehydration, and electrolyte imbalances.

The other statements may indicate areas where patient education is needed, but they do not directly relate to the immediate risk of an Addisonian crisis.

A. institute seizure precautions such as padded side rails. B. assist the patient to perform range-of-motion exercises QID. C. encourage the patient to drink 4000 ml of ﬂuid daily. D. monitor the patient for positive Chvostek’s or Trousseaus sign.

Correct Answer is C

Explanation

The patient with primary hyperparathyroidism has high levels of calcium in the blood (hypercalcemia) which can lead to symptoms such as kidney stones, bone pain, and weakness. High urine calcium levels may also be present due to the increased calcium in the blood.

One important intervention for managing hypercalcemia is to encourage ﬂuid intake to promote increased urine output and prevent the formation of kidney stones. Therefore, the nurse should encourage the patient to drink at least 4000 ml of ﬂuids per day.

Seizure precautions (a), range-of-motion exercises (b), and monitoring for positive Chvostek’s or Trousseaus sign (d) are not directly related to managing hypercalcemia and are not necessary in this case.

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While assessing a patient who has just arrived in the post-anesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains this data. Which is the most important to communicate to the surgeon?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:

Correct Answer is B

Explanation

A patient with primary hyperparathyroidism has a serum calcium level of 14 mg/dl (3.5 mmol/L), phosphorus of 1.7 mg/dl (55 mmol/L), serum creatinine of 2.2 mg/dl (194 mmol/L). and high urine calcium. While the patient awaits surgery, the nurse should:

Correct Answer is C

Explanation

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