A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?

Anxiety

Hyperglycemia

Fever

Dyspnea.

Answer and Explanation

The Correct Answer is D

A.   Anxiety is a common symptom in patients with thyrotoxicosis due to increased metabolic activity and overstimulation of the nervous system. While anxiety can be distressing, it is not typically life- threatening and does not usually require immediate intervention.
B.   Hyperglycemia (high blood glucose levels) can occur in patients with thyrotoxicosis due to increased metabolic rate and potential effects on insulin sensitivity. It requires monitoring and management but typically does not demand immediate intervention unless it is severe and causing other complications.
C.   Fever can be a sign of thyroid storm, a severe form of thyrotoxicosis that can be life-threatening. Elevated body temperature in the context of thyrotoxicosis requires prompt assessment as it may indicate an underlying severe condition or complications.
D.   Dyspnea is a critical symptom that warrants immediate intervention. In the context of thyrotoxicosis, it may indicate a severe complication such as heart failure, thyroid storm, or respiratory distress. Given that dyspnea can lead to compromised oxygenation and potentially life-threatening situations, it is the most urgent symptom to address.

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Correct Answer is B

Explanation

A. While hypercalcemia associated with hyperparathyroidism can lead to neurological symptoms, seizures are not a typical presentation of kidney stones.
B. Sudden onset of severe flank pain in a client with hyperparathyroidism is highly suggestive of a kidney stone. Straining the urine to check for stones is a crucial nursing action.
C. Laxatives are not indicated for the management of kidney stones.
D. While hypercalcemia can lead to cardiac arrhythmias, this is not the immediate priority when the client is experiencing severe flank pain suggestive of kidney stones.

A. Ensure the IV solution is infusing at the prescribed rate. B. Listen to lung sounds. C. Notify the healthcare provider of the findings. D. Check under the back for evidence of bleeding.

Correct Answer is D

Explanation

A. Ensuring that the IV solution is infusing at the prescribed rate is an important task to maintain adequate fluid and electrolyte balance, especially if the client is experiencing signs of shock or low blood pressure. However, this action alone does not address the immediate need to assess or intervene for potential critical issues such as bleeding or severe hemodynamic instability.
B. Listening to lung sounds can help assess for pulmonary complications, such as fluid accumulation or atelectasis, which can be relevant postoperatively. However, in the context of hypotension, tachycardia, and altered mental status, the priority is to address potential critical issues related to circulatory stability and bleeding.
C. It is essential to inform the healthcare provider of the client's condition, but this should be done after initial interventions to stabilize the client. This action is necessary but not the first priority.
D. The first action should be to check for any signs of bleeding, especially after abdominal surgery where internal bleeding is a possibility.

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A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Correct Answer is D

Explanation

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