A nurse assesses a patient who is recovering from a subtotal thyroidectomy.
On the first postoperative day before discharge, the patient states, "I feel numbness and tingling around my mouth.”. What action does the nurse take?
Offer mouth care.
Ask the patient orientation Questions.
Assess for muscle twitching.
Loosen the dressing.
The Correct Answer is C
Choice A rationale
Numbness and tingling around the mouth, or perioral paresthesia, is a classic sign of hypocalcemia, not a symptom to be addressed with mouth care. Offering mouth care would not address the underlying physiological issue, which is a potential disturbance in calcium levels due to accidental removal of or damage to the parathyroid glands during thyroidectomy, a serious and life-threatening complication.
Choice B rationale
Assessing for orientation would be an inappropriate action because the patient's symptoms are physical, not neurological, and do not suggest a change in mental status. The numbness and tingling are a specific finding pointing to a possible parathyroid gland injury and subsequent hypocalcemia. The nurse must prioritize assessment and intervention related to this critical electrolyte imbalance.
Choice C rationale
Muscle twitching, or neuromuscular excitability, is a hallmark sign of severe hypocalcemia. The numbness and tingling around the mouth are early indicators, and checking for muscle twitching, such as Chvostek's or Trousseau's sign, would further confirm the suspected diagnosis. This assessment is a critical and immediate step to evaluate the severity of the electrolyte imbalance and guide appropriate intervention.
Choice D rationale
Loosening the dressing is an action for a patient experiencing symptoms of a hematoma or airway compression, such as difficulty breathing or swelling. The patient's symptom of perioral paresthesia is related to a metabolic disturbance (hypocalcemia) and is not a sign of physical compression. Therefore, loosening the dressing would not alleviate this symptom and is an incorrect intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Percussing the abdomen is a part of a comprehensive assessment but is not the immediate priority in this acute situation. A sudden onset of sharp pain with a rigid abdomen suggests a potential perforation, which is a life-threatening emergency. The priority is to act on this clinical suspicion to prevent rapid deterioration.
Choice B rationale
Taking vital signs is an important nursing action, but in a suspected perforation, it is not the first priority. While vital signs will likely show signs of shock (e.g., hypotension, tachycardia), the most critical action is to alert the healthcare provider so definitive intervention can be initiated without delay.
Choice C rationale
A sudden onset of sharp abdominal pain combined with a tense, rigid abdomen suggests a ruptured peptic ulcer, which is a medical emergency due to the release of gastric or duodenal contents into the peritoneal cavity. This can lead to peritonitis and sepsis, requiring immediate surgical intervention.
Choice D rationale
Administering pain medication without a definitive diagnosis and plan of care could mask critical symptoms and delay necessary surgical intervention. While managing pain is important, it is secondary to addressing the underlying life-threatening emergency of a potential perforation.
Correct Answer is D
Explanation
Choice A rationale
The recommendation for average-risk individuals beginning at age 50 is not to have a fecal occult blood test and a colonoscopy every two years. This interval is less frequent than recommended for some screening methods, but not the standard for the combination of these two tests as per the American Cancer Society. A shorter interval may be indicated for individuals with increased risk factors.
Choice B rationale
The recommendation is not for annual fecal occult blood tests combined with a colonoscopy every year. While a fecal occult blood test is often recommended annually, a colonoscopy is a more invasive and resource-intensive procedure and is not recommended on a yearly basis for average-risk individuals. A yearly colonoscopy is typically reserved for high-risk patients.
Choice C rationale
The recommendation is not to have a fecal occult blood test and a colonoscopy every five years for average-risk individuals. While a colonoscopy alone can be done every five years if a flexible sigmoidoscopy is performed at the same time, the standard recommendation for colonoscopy is less frequent for average-risk individuals, as specified by major health organizations.
Choice D rationale
The American Cancer Society recommends that average-risk individuals beginning at age 50 have a colonoscopy every 10 years and a fecal occult blood test (FOBT) annually. These guidelines are based on large-scale population studies and clinical data showing that this screening interval is effective for detecting early-stage colorectal cancer and precancerous polyps, improving patient outcomes.
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