A client has been diagnosed with hypothyroidism. What information should the nurse obtain when conducting a focused assessment? Select all that apply.

Weight gain

Constipation

Rapid pulse

Decreased energy

Hypertension

Answer and Explanation

Correct Answer : A,B,D

Choice A Reason: Weight gain is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the metabolism to slow down and the body to store more fat.

Choice B Reason: Constipation is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the gastrointestinal motility to decrease and the stools to become hard and dry.

Choice C Reason: Rapid pulse is not a common finding in hypothyroidism, but it may indicate other conditions such as hyperthyroidism or anxiety.

Choice D Reason: Decreased energy is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the body to feel tired and sluggish.

Choice E Reason: Hypertension is not a common finding in hypothyroidism, but it may indicate other conditions such as renal disease or cardiovascular disease.

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Correct Answer is D

Explanation

Choice A Reason: Irrigating the fistula with 3 mL of normal saline solution is not a correct way to assess the patency of the fistula, as it may cause bleeding, infection, or dislodgement of the fistula.

Choice B Reason: Flushing the fistula with 1 mL of heparin solution once per shift is not a correct way to assess the patency of the fistula, as it may cause clotting, infection, or allergic reaction.

Choice C Reason: Infusing 50 mL of normal saline once per 24 hours is not a correct way to assess the patency of the fistula, as it may cause fluid overload, hypertension, or edema.

Choice D Reason: Palpating for a vibrating sensation at the fistula site is a correct way to assess the patency of the fistula, as it indicates that there is adequate blood flow through the fistula. This sensation is also known as a thrill.

A. Keeping scissors at the bedside B. Providing good mouth care C. Deflating the balloon on a regular basis D. Monitoring IV fluid intake

Correct Answer is A

Explanation

Choice A Reason: Keeping scissors at the bedside is the most important safety intervention for this client, as it allows for quick removal of the tube in case of airway obstruction or bleeding.

Choice B Reason: Providing good mouth care is an important intervention for this client, but it is not the most important, as it helps to prevent oral infections and discomfort.

Choice C Reason: Deflating the balloon on a regular basis is not an appropriate intervention for this client, as it may cause bleeding or displacement of the tube.

Choice D Reason: Monitoring IV fluid intake is an important intervention for this client, but it is not the most important, as it helps to prevent fluid overload or dehydration.

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A client has been diagnosed with hypothyroidism. What information should the nurse obtain when conducting a focused assessment? Select all that apply.

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Naxlex Comprehensive Predictor Exams

I can help you with formatting and editing the text. Here are the edited texts: Text 1: A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?

Correct Answer is D

Explanation

A client diagnosed with esophageal varices has a Sengstaken-Blakemore tube. What is the most important safety intervention for this client?

Correct Answer is A

Explanation

A nurse reinforces instructions to a client with hypothyroidism about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions?

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