Question

What will be an ideal response?

Answer 1

• Your assessment should begin with the ABCs.
Airway: Assess for hoarseness and weak voice because of edema or damage to the recurrent laryngeal
nerve; ask C.P. to immediately report any sensation of swelling or tightening in her airway.
Breathing: Assess for any signs of respiratory distress, such as stridor, and ask C.P. to immediately
report any choking sensation or difficulty breathing or swallowing.
Circulation: Assess patency and adequacy of the IV access to accommodate rapid IV infusion or
the irritant calcium gluconate as needed. Assess for hemorrhage into the neck tissues; check the
surgical site and dressing; note swelling or ecchymosis; monitor VS.
• Check for tetany (calcium deficiency secondary to parathyroid tissue removal).
• Check to see whether the ice bag needs to be refilled.

Answer 2

You need to evaluate what care K.D. will require on discharge and determine his ability to obtain
necessary care. Assess K.D.'s support system and availability of community resources. This includes
key factors, such as: Does he have significant others who will help with posthospital care? Is there
someone to bring him to the hospital if necessary? Who in the community will be responsible for
coordinating his care after discharge? What medical follow-up will be necessary and with whom? Can
he afford the necessary care? Does he have access to counseling after discharge? What access does
he have to community resources, and which may he benefit from?

Answer 3

• C.P.'s airway might become compromised because of edema from the surgery or internal
hemorrhage at the surgical site. You should make certain there is a tracheostomy tray and
intubation tray at the bedside.
• Humidified oxygen and suction equipment should be at the bedside and operational.
• Place a suture-removal set in the room (to relieve respiratory obstruction if internal hemorrhage
occurs).
• Place an IV infusion pump in the room. An extra liter of normal saline should be available for rapid
infusion in the event of hemorrhage.
• Place an ampule of calcium gluconate at the bedside (in the event tetany develops).

Answer 4

J.B. and his wife are able to state the following:
• The names of each of the drugs prescribed along with the dose, the reason for use, possible
adverse effects, and the importance of taking drugs on time
• At least four ways to achieve maximal muscle strength or endurance
• The signs and symptoms of cholinergic and MG crises and how to intervene in a crisis situation
• That J.B. will wear a form of medical alert identification and carry written information regarding his
prescribed drugs and dosages

Answer 5

Spend time with K.D. and encourage him to express his feelings and concerns. K.D. should be
offered appropriate referrals, include psychiatry or counseling services. Help him identify available
community support services, and encourage him to use those services after discharge. He may also
be considered for antidepressant use.