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 C
Explanation
Rationale:
A. Moist mucous membranes would indicate adequate hydration, which is not typically seen in diabetes insipidus.
B. Bounding peripheral pulses are associated with conditions of fluid overload, not diabetes insipidus.
C. Poor skin turgor is a sign of dehydration, which is a common finding in diabetes insipidus due to excessive urine output leading to significant fluid loss.
D. Bradycardia is not typically associated with diabetes insipidus; tachycardia might be seen due to dehydration and hypovolemia.
Correct Answer is D
Explanation
Rationale:
A. Children with Addison’s disease often require increased sodium intake, especially during periods of stress or illness, due to the lack of aldosterone.
B. Addison's disease typically causes fluid volume deficit rather than excess.
C. Addison's disease is more commonly associated with hypoglycemia rather than hyperglycemia.
D. Teaching the parents about cortisol replacement therapy is crucial, as this is the primary treatment for managing Addison’s disease. The child will need lifelong hormone replacement to compensate for the lack of cortisol.