The nurse provides care for a client who had a subtotal thyroidectomy 48 hours ago. Which question is the highest priority for the nurse to ask?
"Are you experiencing any nausea at this time?"
"Have you noticed any decrease in muscle weakness?"
"Do you have any numbness or tingling of your hands?"
"Do you have any breathing difficulties while walking?"
The Correct Answer is C
Choice A reason: "Are you experiencing any nausea at this time?" is not the highest priority question because it is a common side effect of anesthesia, which is usually given during a thyroidectomy. Nausea is not a life-threatening complication, and it usually resolves within a few days after surgery.
Choice B reason: "Have you noticed any decrease in muscle weakness?" is not the highest priority question because it is a sign of improvement in the client's condition. A subtotal thyroidectomy is a surgical procedure that removes part of the thyroid gland, which is responsible for producing hormones that regulate the metabolism, growth, and development of the body. A client who has a thyroidectomy may have hypothyroidism, which is a condition where the thyroid gland does not produce enough hormones, causing symptoms such as fatigue, weight gain, and muscle weakness. A decrease in muscle weakness indicates that the client is responding well to the hormone replacement therapy, which is usually given after a thyroidectomy.
Choice C reason: "Do you have any numbness or tingling of your hands?" is the highest priority question because it is a sign of a possible complication of a thyroidectomy, which is hypocalcemia. Hypocalcemia is a condition where the blood has a low level of calcium, which is an electrolyte that helps regulate the nerve and muscle function, including the heart. A thyroidectomy can cause hypocalcemia if the parathyroid glands, which are small glands that are located behind the thyroid gland and produce a hormone that regulates the calcium level in the blood, are accidentally damaged or removed during the surgery. Hypocalcemia can cause symptoms such as numbness and tingling of the hands, feet, and lips, muscle spasms, seizures, and cardiac arrhythmias, which can be fatal if not treated promptly.
Choice D reason: "Do you have any breathing difficulties while walking?" is not the highest priority question because it is a sign of a possible complication of a thyroidectomy, which is tracheal compression. Tracheal compression is a condition where the trachea, which is the airway that connects the mouth and nose to the lungs, is squeezed or narrowed by the swelling or bleeding of the tissues around the thyroid gland. Tracheal compression can cause symptoms such as difficulty breathing, hoarseness, stridor, and cyanosis, which can be life-threatening if not treated promptly. However, tracheal compression is more likely to occur immediately after surgery, not 48 hours later.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Blood clots in the peripheral blood vessels are not a cause of anemia, but a complication of it. They may occur due to increased blood viscosity, reduced blood flow, or hypercoagulability. They may cause tissue ischemia, pain, and necrosis.
Choice B reason: Decrease in bone marrow platelet production is not a cause of anemia, but a result of it. It may occur due to bone marrow suppression, infiltration, or destruction. It may cause bleeding, bruising, and petechiae.
Choice C reason: Increase in the number of circulating reticulocytes is not a cause of anemia, but a sign of it. Reticulocytes are immature red blood cells that are released from the bone marrow to compensate for the loss of mature red blood cells. They indicate a regenerative response to anemia.
Choice D reason: Redistribution of blood to the heart and brain is a compensatory mechanism for anemia. It occurs to maintain adequate oxygen delivery to the vital organs. It causes vasoconstriction and shunting of blood away from the skin and mucous membranes, resulting in pallor.
Correct Answer is A
Explanation
Choice A reason: Colon cancer is the most likely disorder that the client is at risk to develop because it is a type of cancer that affects the large intestine, which is the part of the digestive tract that absorbs water and forms stool. Colon cancer can be caused by various factors, such as genetics, diet, or inflammation. Ulcerative colitis is a chronic inflammatory bowel disease that causes ulcers and inflammation in the inner lining of the colon and rectum, which are the last parts of the large intestine. Ulcerative colitis can increase the risk of colon cancer by causing DNA damage and abnormal cell growth in the colon.
Choice B reason: Crohn disease is not the most likely disorder that the client is at risk to develop because it is a different type of inflammatory bowel disease that causes inflammation and damage in any part of the digestive tract, from the mouth to the anus. Crohn disease can be caused by various factors, such as genetics, immune system, or bacteria. Ulcerative colitis and Crohn disease have some similar symptoms, such as diarrhea, abdominal pain, or weight loss, but they are not the same condition and do not increase the risk of each other.
Choice C reason: Lactase deficiency is not the most likely disorder that the client is at risk to develop because it is a condition where the body does not produce enough lactase, which is an enzyme that breaks down lactose, which is a sugar that is found in milk and dairy products. Lactase deficiency can cause symptoms such as bloating, gas, or diarrhea after consuming lactose. Lactase deficiency can be caused by various factors, such as genetics, age, or intestinal injury. Ulcerative colitis does not affect the production of lactase, but it can cause lactose intolerance, which is a condition where the body cannot digest lactose properly due to the inflammation and damage of the colon.
Choice D reason: Irritable bowel syndrome is not the most likely disorder that the client is at risk to develop because it is a functional disorder that affects the movement and sensitivity of the bowel, causing symptoms such as abdominal pain, cramping, or constipation. Irritable bowel syndrome can be triggered by various factors, such as stress, food, or hormones. Irritable bowel syndrome does not cause inflammation or damage to the bowel, unlike ulcerative colitis, and it does not increase the risk of colon cancer.
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