A 40-year-old female client has a family history of "thyroid problems" and is being seen by the primary healthcare provider for unintentional weight loss, irritability, and chest discomfort. Her probable diagnosis is hyperthyroidism, which the primary healthcare provider plans to confirm by laboratory testing.
What additional physical assessment findings would the nurse expect to be present in this client?
Select all that apply.
Diaphoresis
Insomnia
Hypotension
Decreased deep tendon reflexes.
Constipation
Correct Answer : A,B,E
Answer c is incorrect because hyperthyroidism typically causes hypertension, not hypotension. Answer d is also incorrect because hyperthyroidism typically causes increased, not decreased, deep tendon reflexes. Answer f is incorrect because hyperthyroidism typically causes diarrhea, not constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Based on the assessment findings presented, the nurse would suspect a urinary tract infection (UTI). The client's symptoms of acute confusion, urinary frequency and incontinence, and elevated WBC count with bands suggest a possible infection. Dehydration or diabetic ketoacidosis could also cause confusion and fatigue, but these conditions are less likely given the normal BMP and CBC results.
Hepatitis would not typically present with these specific symptoms.
Correct Answer is D
Explanation
The nurse should quickly assess the patient's vital signs to check for signs of shock and instability. If the vital signs are unstable, the nurse should initiate appropriate interventions to stabilize the patient, such as administering oxygen, starting IV fluids, and providing continuous cardiac monitoring. Based on the sudden onset of severe upper abdominal pain, diaphoresis, and a firm abdomen, the nurse should suspect a possible perforation or bleeding related to the peptic ulcer. This is a medical emergency that requires immediate intervention. Therefore, the nurse should prioritize notifying the healthcare provider and preparing the patient for urgent medical evaluation.
Option A, irrigating the NG tube, is not appropriate in this situation and may further exacerbate the patient's condition if the ulcer has perforated.
Option B, elevating the foot of the bed, is also not appropriate as it does not address the patient's current symptoms.
Option C, giving the ordered antacid, may not be effective in addressing the severity of the patient's symptoms and should be postponed until the healthcare provider has evaluated the patient.
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