A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?
Airway patency
Temperature
Pain control
Urination
The Correct Answer is A
Rationale:
A. Airway patency is the highest priority following a thyroidectomy due to the risk of airway obstruction from swelling or hematoma formation near the surgical site. Compromised airway can lead to respiratory distress and requires immediate attention.
B. While monitoring temperature is important for detecting potential infections, it is not the immediate priority.
C. Pain control is important for comfort and recovery, but it is not life-threatening.
D. Urination should be monitored postoperatively, but it is not as critical as ensuring a patent airway.
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Correct Answer is ["A","B","D","E"]
Explanation
Rationale:
A. Purple striae (stretch marks) are common in Cushing's syndrome due to skin thinning and the redistribution of fat.
B. A "moon face" is a classic sign of Cushing's syndrome, caused by fat deposition in the face.
C. Bronze pigmentation is associated with Addison's disease, not Cushing's syndrome.
D. A "buffalo hump," or fat accumulation on the upper back, is another characteristic feature of Cushing's syndrome.
E. Poor wound healing is expected in Cushing's syndrome due to the effects of prolonged exposure to high cortisol levels, which impair immune function and tissue repair.
Correct Answer is ["A","C","D","E"]
Explanation
Rationale:
A. Reducing cholesterol and saturated fat intake is important for managing cardiovascular health, which is crucial for clients with diabetes to prevent complications such as heart disease and stroke.
B. Sustaining hyperglycemia is incorrect; it actually contributes to complications like neuropathy, retinopathy, and nephropathy. The goal is to maintain blood glucose levels within the target range.
C. Maintaining optimal blood pressure is essential in preventing diabetic nephropathy, as high blood pressure can damage the kidneys and worsen diabetic kidney disease.
D. Increasing physical activity helps improve insulin sensitivity, control blood glucose levels, and reduce the risk of complications associated with diabetes.
E. Smoking cessation is critical in reducing the risk of cardiovascular disease, which is higher in clients with diabetes. Smoking can exacerbate the complications of diabetes.