Physiological Adaptation Q 116

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Nurse Eve is caring for a client who had a thyroidectomy 12 hours ago for treatment of Grave’s disease. The nurse would be most concerned if which of the following was observed?

  

     A. Blood pressure 138/82, respirations 16, oral temperature 99 degrees Fahrenheit.

     B. The client supports his head and neck when turning his head to the right.

     C. The client spontaneously flexes his wrist when the blood pressure is obtained.

     D. The client is drowsy and complains of sore throat.

    

    

Correct Answer: C. The client spontaneously flexes his wrist when the blood pressure is obtained.

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Carpal spasms indicate hypocalcemia.

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Option A: The vital signs are all within the normal range.

Option B: Supporting the head and neck while turning protects the surgical site from dehiscence.

Option D: Drowsiness may be a side effect of the anesthesia used during surgery and will fade away eventually; a sore throat is a normal finding after thyroid surgery.

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