The nurse has reviewed the Nurses' Notes and Vital Signs at 0900.
Complete the following sentence by using the lists of options.
The client is most at risk for
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
- seizures: If a thyroid storm occurs, the client can experience seizures due to the extreme metabolic disturbances and nervous system overstimulation it causes. Seizures would be a serious complication indicating worsening neurological function. Therefore, the client’s risk for seizures is directly related to the risk of developing a thyroid storm after surgery.
- paralytic ileus: Paralytic ileus involves bowel inactivity post-surgery, but the client had normoactive bowel sounds before surgery and no current documentation of absent or significantly reduced bowel activity. Therefore, this is not the most immediate risk based on current findings.
- pneumonia: The client is receiving oxygen therapy and has a slightly increased respiratory rate after surgery, but no signs of labored breathing, abnormal lung sounds, or infection are reported. Although inactivity can contribute to pneumonia risk postoperatively, there are no current findings indicating that pneumonia is developing right now.
- thyroid storm: The client had a thyroidectomy after presenting with signs of severe hyperthyroidism (weight loss, heat intolerance, anxiety, exophthalmos, goiter) and elevated T3 and T4 levels. Thyroid storm is a critical risk after thyroidectomy due to sudden hormone release, and it can cause life-threatening complications such as high fever, hypertension, tachycardia, and altered mental status.
- bowel sounds: The bowel sounds were normal before surgery, and there is no mention of significant gastrointestinal changes postoperatively. Bowel sounds alone are not the critical factor leading to the client’s highest current risk.
- inactivity: The client is currently lethargic after surgery and under the effects of anesthesia, which reduces movement and activity. Inactivity can cause decreased lung expansion and increase the risk of pulmonary complications like pneumonia. Although this is a concern, inactivity is not the client's most critical immediate risk compared to thyroid storm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Rigid expectations of behavior: Perpetrators of child abuse often have unrealistic and rigid expectations of children’s behavior. When children do not meet these expectations, it can lead to frustration, anger, and abusive responses from the caregiver.
B. Self-blame for financial problems: While financial stress can be a risk factor for family dysfunction, self-blame alone is not a recognized direct characteristic of child abuse perpetrators. Abusive behavior is more often linked to blaming others and lack of coping skills.
C. Laissez-faire leadership style: A laissez-faire leadership style involves being hands-off or permissive, which is not typically associated with abusive behaviors. Abusers are often controlling and overly strict, not permissive.
D. High self-esteem: High self-esteem is generally associated with healthy interpersonal behavior. Low self-esteem, poor coping mechanisms, and unresolved personal trauma are more commonly seen in those who commit child abuse.
Correct Answer is C
Explanation
A. The infant was born large for gestational age: Being large for gestational age is not recognized as a risk factor for child maltreatment. Risk factors are more often related to family dynamics, age, and social stressors rather than birth weight alone.
B. The infant has otitis media: Otitis media, or a middle ear infection, is a common pediatric illness and is not itself a risk factor for maltreatment. It reflects normal childhood health issues rather than abuse or neglect.
C. The infant is younger than 1 year of age: Infants under 1 year are particularly vulnerable to maltreatment because of their total dependence on caregivers and inability to communicate effectively. This age group is at the highest risk for serious injury from abuse.
D. The infant's guardians are both over the age of 30: Parental age over 30 does not inherently increase the risk for child maltreatment. Other factors like substance abuse, history of being abused, and high stress levels are more closely linked to maltreatment risk.
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