Registered Nurse (RN) Endocrine Licensure Exam

Which combination of signs and symptoms requires immediate nursing intervention for a patient who recently had a thyroidectomy?

1. Heart rate of 120, blood pressure 220/102, temperature 103.2 'F

2. Heart rate of 35, blood pressure 60/43, temperature 95.3 'F

3. Soft hair, irritable, diarrhea

4. Constipation, drowsiness, goiter

The correct answer is: Heart rate of 120, blood pressure 220/102, temperature 103.2 'F

The combination of signs and symptoms that includes a heart rate of 120, blood pressure of 220/102, and a temperature of 103.2°F indicates a critical condition requiring immediate nursing intervention. This profile suggests potential hyperthyroid activity or a thyroid storm, which can occur after a thyroidectomy due to the sudden release of thyroid hormone from the underlying tissues. Elevated heart rate, significantly high blood pressure, and elevated temperature reflect an overstimulation of the cardiovascular and metabolic systems, which can rapidly lead to serious complications, including cardiac dysrhythmias, heart failure, or even mortality if not addressed promptly. In contrast, the other options present signs and symptoms that are less acute or may lead to a slower deterioration. The second option indicates bradycardia and hypotension, which are serious but can be part of a different set of complications. The third option showcases symptoms commonly linked with hyperthyroidism, but they don't indicate an immediate threat to the patient's stability. Lastly, the fourth option denotes symptoms that may suggest hypothyroidism or insufficient hormone levels but are not urgent in nature. Thus, the symptoms in the first option demand swift assessment and intervention to prevent life-threatening complications.