Chapter 58: Assessment of the Endocrine System Ignatavicius: Medical-Surgical Nursing, 10th Edition 2024

The nurse is planning health teaching for a client starting on levothyroxine. What health teaching about this drug would the nurse include? a. The need to take the drug when the client feels fatigued and weak. b. The need to report chest pain and dyspnea when starting the drug. c. The need to check blood pressure and pulse every day. d. The need to rotate injection sites when giving self the drug. - CORRECT ANSWERS-ANS: B Levothyroxine is a replacement hormone for clients who have hypothyroidism and is taken orally for life. Vital signs do not have to be checked every day, but the client should report any chest pain and dyspnea when first starting the drug. A nurse assesses a client who is recovering from a subtotal thyroidectomy and observes the development of stridor. What is the priority action for the nurse to take? a. Apply oxygen via nasal cannula at 2/Lmin. b. Document the finding and assess the client hourly. c. Place the client in high-Fowler position in the bed. d. Contact the Rapid Response Team and prepare for intubation. - CORRECT ANSWERS-ANS: D Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open. A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the first postoperative day before discharge, the client states, "I feel numbness and tingling around my mouth." What action does the nurse take? a. Offer mouth care. b. Loosen the dressing. c. Assess for muscle twitching. d. Ask the client orientation questions. - CORRECT ANSWERS-ANS: C Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse would assess for muscle twitching and, if present, notify the surgeon or Rapid Response Team to give calcium gluconate or other IV calcium replacement. Mouth care, loosening the dressing, and orientation questions do not provide important information to prevent complications of low calcium levels. A nurse assesses a client on the medical-surg