A client in the emergency department is experiencing an acute asthma exacerbation, which has not improved with albuterol nebulizer treatments. The client is obviously struggling to breathe. The nurse anticipates that intubation and mechanical ventilation will be needed based on which of the following assessment findings?

Tachycardia

Anxiety

Hypotension

Loud expiratory wheezing

Answer and Explanation

The Correct Answer is C

A.   Tachycardia (rapid heart rate) can occur in response to hypoxia (low oxygen levels), stress, or as a side effect of medications like albuterol. While tachycardia is a concerning sign in the context of an asthma exacerbation, it alone does not directly indicate the need for intubation and mechanical ventilation. It is often managed by addressing the underlying respiratory distress and improving oxygenation.
B.   Anxiety is common in patients struggling to breathe, as they may feel frightened or panicked due to their difficulty breathing. However, anxiety itself is not an indicator for intubation and mechanical ventilation. It is a symptom of respiratory distress but does not directly assess the severity of the physiological need for mechanical support.
C.   Hypotension (low blood pressure) in the context of an asthma exacerbation can be a sign of severe illness, possibly indicating shock or severe respiratory distress leading to reduced cardiac output. While hypotension is a serious concern, it is less directly related to the immediate need for intubation and mechanical ventilation compared to other indicators of respiratory failure.
D.   Loud expiratory wheezing indicates significant airway obstruction but does not necessarily reflect the need for intubation and mechanical ventilation. Wheezing can be a sign of severe asthma but may not be sufficient on its own to necessitate intubation if the patient can still maintain adequate oxygenation and ventilation.

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Correct Answer is C

Explanation

A. Mucositis and diarrhea are side effects commonly associated with chemotherapy but are not directly related to myelosuppression. These symptoms are due to the impact of chemotherapy on rapidly dividing cells in the gastrointestinal tract.
B. Nausea and vomiting are common side effects of chemotherapy, primarily due to the treatment's impact on the gastrointestinal tract and the central nervous system.
C. Fever and chills are manifestations directly related to myelosuppression. Myelosuppression leads to a decrease in white blood cells (leukocytes), which compromises the immune system. This increased susceptibility to infection can result in symptoms such as fever and chills. These symptoms are indicative of potential infections or sepsis, which are more common in patients with compromised immune systems due to myelosuppression.

D. Alopecia (hair loss) and weight loss are common side effects of chemotherapy, but they are not directly related to myelosuppression. Alopecia results from the effects of chemotherapy on rapidly dividing hair follicle cells, while weight loss can be a consequence of changes in metabolism or appetite due to chemotherapy.

A. "It is caused by the overproduction of T3, T4, and calcitonin by the thyroid gland." B. "It is caused by the lack of production of adrenocorticotropic hormone by the pituitary gland." C. "It is caused by the lack of production of thyroid stimulating hormone by the pituitary gland." D. "It is caused by the lack of production of aldosterone by the adrenal gland."

Correct Answer is C

Explanation

A. Secondary hypothyroidism is characterized by insufficient production of thyroid hormones (T3 and T4) due to inadequate stimulation from the pituitary gland, not due to overproduction. Overproduction of thyroid hormones would typically be associated with hyperthyroidism, not hypothyroidism.
B. Adrenocorticotropic hormone (ACTH) stimulates the adrenal glands to produce cortisol. A deficiency in ACTH would lead to adrenal insufficiency or Addison's disease, not secondary hypothyroidism.
Secondary hypothyroidism specifically involves a deficiency in thyroid-stimulating hormone (TSH), not ACTH.
C. Secondary hypothyroidism is caused by inadequate production of thyroid-stimulating hormone (TSH) by the pituitary gland. TSH is necessary for stimulating the thyroid gland to produce thyroid hormones (T3 and T4). When the pituitary gland does not produce enough TSH, the thyroid gland is not adequately stimulated, leading to low levels of thyroid hormones in the blood.
D. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and potassium levels, as well as blood pressure. A deficiency in aldosterone is associated with conditions such as
Addison’s disease or primary adrenal insufficiency, not secondary hypothyroidism. Secondary
hypothyroidism specifically relates to issues with TSH production, not aldosterone.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is receiving chemotherapy for breast cancer is experiencing myelosuppression as a side effect of the treatment. Which of the following is a manifestation directly related to myelosuppression?

Correct Answer is C

Explanation

A staff nurse is teaching a client who has secondary hypothyroidism about the disease process. The client asks the nurse what causes secondary hypothyroidism. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

The nurse is reviewing the results of the client's echocardiogram and observes that the ejection fraction is 30%. Which lab result would the nurse expect to be elevated for a client with this ejection fraction?

A client is scheduled for an adrenocorticotropic hormone (ACTH) stimulation test to help diagnose suspected Addison's disease. What should the nurse include when teaching the client about this test?

A nurse is providing discharge education to a client who has undergone extracapsular cataract extraction surgery. What should the nurse include in the discharge teaching? (Select all that apply.)

A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication?

A client with a cold sore on the lip has been diagnosed with herpes simplex virus. Which neurological disorder may the client be at risk for in the future?

The nurse is providing care for a geriatric patient with loss of hearing acuity over the past several years. Which statement by the nurse is most accurate?

A nurse is assessing a client who is 12 hours postoperative following a thyroidectomy. Which of the following findings is indicative of thyrotoxic crisis?

A nurse is caring for a client who has undergone a bilateral adrenalectomy. The nurse monitors for which of the following signs of Addisonian crisis?