What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?
"This IV infusion makes me urinate more often than usual."
"I'm most comfortable when the head of the bed is raised."
"The dressing over my incision feels like it is too tight."
"When I get out of bed quickly, I feel a little dizzy."
The Correct Answer is C
A. Increased urination due to IV fluids is common and not immediately concerning.
B. Comfort with an elevated head of bed is typical postoperatively.
C. A tight dressing could indicate swelling or a potential complication such as hematoma, which can compromise the airway and requires immediate assessment.
D. Dizziness upon standing is common and not as urgent as potential airway compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Shuffling gait and stooped posture are common side effects of antipsychotic medications and may require intervention but are not immediately dangerous.
B. Rocking back and forth in the chair can be a self-soothing behavior in individuals with schizophrenia and usually does not require immediate intervention.
C. Muscle spasms of the back and neck (dystonia) can be a sign of a serious side effect of antipsychotic medications known as extrapyramidal symptoms and require immediate intervention to prevent complications such as airway obstruction.
D. Lip smacking and frequent eye blinking can indicate tardive dyskinesia, a long-term side effect of antipsychotic medication, but it is not an immediate emergency.
Correct Answer is A
Explanation
A. Guillain-Barre syndrome is a condition that can occur after an upper respiratory infection and is characterized by progressive weakness, numbness, and sometimes difficulty swallowing, which align with the client's symptoms.
B. Mycoplasma pneumonia primarily affects the respiratory system and does not typically cause lower extremity numbness and difficulty swallowing.
C. Cytomegalovirus can cause a range of symptoms but is not specifically associated with lower extremity numbness and difficulty swallowing.
D. Epstein-Barr virus is linked to infectious mononucleosis and does not typically cause lower extremity numbness and difficulty swallowing.
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