A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

Neck stiffness

Hoarseness

Moderate serosanguineous drainage

Muscle twitching

Answer and Explanation

The Correct Answer is D

Muscle twitching can a feature of hypocalcemia which may eventually lead to tetany. It is therefore, necessary to report muscle twitching to avoid serious complications such as bronchospasm.
A.   Neck stiffness is anticipated due to manipulation of neck muscles during surgery.
B.   Hoarseness occurs due to injury of recurrent laryngeal nerve or manipulation of the vocal cords and surrounding structures during surgery.
C.   Some drainage from the incision site is expected after surgery, including a total thyroidectomy
D.   Muscle twitching may indicate neuromuscular irritability or electrolyte imbalances, which could be unrelated to the thyroidectomy surgery.

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Correct Answer is C

Explanation

C. It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
A. This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
D. While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.

A. Loss of hearing B. Muscle wasting C. Paresthesia D. Changes in vision

Correct Answer is C

Explanation

C. Paresthesia, or abnormal sensations like tingling, numbness, or burning, is a common neurological manifestation of pernicious anemia due to damage to the peripheral nerves caused by vitamin B12 deficiency. Paresthesia can affect balance and coordination, increasing the risk of falls and injuries, and thus posing a risk to the client's safety.
A. Loss of hearing is not typically associated with pernicious anemia.
B. Muscle wasting is not a typical manifestation of pernicious anemia. However, weakness and fatigue are common symptoms due to anemia resulting from decreased oxygen-carrying capacity of the blood.

D. While changes in vision can impact the client's safety, they are not as directly associated with pernicious anemia as paresthesia, which affects mobility and balance.

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A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?

Correct Answer is C

Explanation

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