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The nurse has reviewed the Vital Signs at 1000.

Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

"Use sunglasses if your eyes are sensitive to light."

"Continue eating foods with protein."

"Remain on bedrest for 3 to 5 days following discharge."

"You need to support your neck when coughing or moving

"You will no longer need to take any medications for your thyroid now that you have had surgery."

Answer and Explanation

Correct Answer : A,B,D

"Use sunglasses if your eyes are sensitive to light.": After thyroid surgery, especially if the client has Graves’ disease and associated exophthalmos, the eyes may remain sensitive to light. Wearing sunglasses helps protect the eyes from irritation and prevents further discomfort while healing progresses.
"Continue eating foods with protein.": Maintaining adequate protein intake is important for healing after surgery. Protein supports tissue repair, immune function, and recovery, making it an essential part of the client’s postoperative nutrition plan.
"Remain on bedrest for 3 to 5 days following discharge.": Prolonged bedrest after thyroid surgery is not recommended. Early ambulation helps prevent complications such as blood clots and promotes recovery. Clients are usually encouraged to resume light activities shortly after surgery.
"You need to support your neck when coughing or moving.": After thyroidectomy, supporting the neck when coughing, sneezing, or repositioning helps protect the surgical site, reduces strain on the incision, and minimizes discomfort, promoting safer healing.
"You will no longer need to take any medications for your thyroid now that you have had surgery.": This is incorrect because many clients require lifelong thyroid hormone replacement therapy after a thyroidectomy to maintain normal metabolic function, depending on how much thyroid tissue was removed.

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Correct Answer is D

Explanation

A. Promote bonding by encouraging the guardians to formula feed their newborn: Bonding occurs through close physical contact, responsiveness, and nurturing care, regardless of the feeding method. Bonding is important regardless of feeding method, but feeding choice should be based on the guardians’ preference, not directed solely by the nurse. Formula feeding is not necessary for promoting bonding.

B. Encourage guardians to allow relatives to provide the majority of the care for their newborn: Guardians should be encouraged to provide the majority of the newborn's care themselves to strengthen attachment and build confidence in their parenting abilities.

C. Ensure guardians know that criticism of newborn care is acceptable: Criticism can undermine the guardians' confidence and create stress. Support and positive reinforcement are important for helping new parents feel secure in their roles.

D. Inform guardians how to respond to their newborn's cues: Teaching guardians how to recognize and respond to their newborn's cues, such as hunger, discomfort, or need for interaction, promotes bonding, supports emotional development, and strengthens the parent-newborn relationship.

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL) B. A client who has a spinal cord injury and needs a dressing change C. A client who has a temperature of 38.4° C (101.1 F) and appears confused D. A client who had a hip arthroplasty and is requesting pain medication

Correct Answer is C

Explanation

A. A client who is receiving an enteral tube feeding and has a blood glucose level of 155 mg/dL (74 to 106 mg/dL): A mildly elevated blood glucose level is not immediately life-threatening and can be managed after addressing more urgent issues. This client is stable at the moment.

B. A client who has a spinal cord injury and needs a dressing change: While important for preventing infection, a scheduled dressing change is not an immediate threat to the client’s life or health and can be safely performed after more urgent concerns are addressed.

C. A client who has a temperature of 38.4° C (101.1° F) and appears confused: Fever and new-onset confusion suggest a possible infection, such as sepsis or urinary tract infection, especially in older adults. This situation indicates a potential life-threatening condition and requires immediate assessment and intervention.

D. A client who had a hip arthroplasty and is requesting pain medication: Managing pain is important, but it is not immediately life-threatening. After addressing the client with fever and confusion, attending to the client's pain needs would be appropriate.

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The nurse has reviewed the Vital Signs at 1000. Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

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The nurse has reviewed the Vital Signs at 1000.

Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.