the nurse is caring for a postthyroidectomy patient at risk for hypocalcemia what action should the nurse take when assessing for hypocalcemia

ATI RN

Fluid and Electrolytes ATI

1. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?

A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
B. Observe for swelling of the neck, tracheal deviation, and severe pain.
C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Correct answer: D

Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.

2. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:

A. She will need her medications adjusted and be readmitted for a complete workup.
B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
C. Post-surgical confusion is common, and it's safe not to urinate at night.
D. Confusion after surgery is typical in the elderly due to sleep loss.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.

3. What fluid is found in spaces between the cells?

A. Intracellular fluid
B. Interstitial fluid
C. Plasma
D. Electrolyte

Correct answer: B

Rationale: The correct answer is B, Interstitial fluid. Interstitial fluid is the fluid that surrounds and occupies the spaces between cells, providing them with nutrients and removing waste. Choices A, C, and D are incorrect because intracellular fluid refers to fluid inside cells, plasma refers to the liquid component of blood, and electrolyte refers to substances that dissociate into ions in solution, affecting fluid balance but not specifically found in spaces between cells.

4. Extracellular fluid includes:

A. plasma and intracellular fluid.
B. interstitial and intracellular fluids.
C. plasma and interstitial fluid.
D. plasma, interstitial fluid, and intracellular fluid.

Correct answer: C

Rationale: The correct answer is C: 'plasma and interstitial fluid.' Extracellular fluid consists of all body fluids outside the cells, primarily including plasma (the liquid component of blood) and interstitial fluid (the fluid between cells). Choices A, B, and D are incorrect because intracellular fluid is located within the cells, not in the extracellular fluid compartment.