A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement?
Offer additional blankets and a warm drink.
Note the client's most recent hemoglobin level.
Administer prescribed dose of levothyroxine.
Assess for presence of non-pitting edema.
The Correct Answer is C
A) Incorrect- While providing comfort measures like blankets and warm drinks can help the client feel more comfortable, they do not address the underlying thyroid hormone imbalance.
B) Incorrect- Hemoglobin level is not directly related to the client's symptoms or the thyroid hormone imbalance. Monitoring hemoglobin is important in assessing anemia but is not the priority in this case.
C) Correct- The client's symptoms (raspy voice, cold intolerance, fatigue) along with an elevated TSH and low T3 and T4 levels suggest hypothyroidism. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. Administering the prescribed dose of levothyroxine is crucial to address the thyroid hormone imbalance and alleviate the symptoms.
D. Incorrect- Non-pitting edema is not a common symptom of hypothyroidism. The client's symptoms and lab results are more indicative of hypothyroidism, and addressing the thyroid hormone imbalance is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Situation: Increasing confusion of the client.
The nurse should start by providing the current situation, which is the client's increasing confusion. This is crucial information as it indicates a change in the client's condition and may require immediate attention.
Background: Fall at home as reason for admission.
Next, the nurse should provide the background information, which includes the reason for admission, in this case, the fall at home. This helps the healthcare provider understand the context and potential contributing factors to the client's current condition. Assessment: Currently prescribed medications.
After providing the background, the nurse should discuss the assessment findings. In this case, it would be appropriate to mention the client's currently prescribed medications. This information can help the healthcare provider assess for any medication-related issues or interactions that could be contributing to the client's confusion.
Recommendation: Client's healthcare power of attorney.
Lastly, the nurse should provide the recommendation, which in this case is the client's healthcare power of attorney. This information is important as it identifies the designated decision-maker for the client's healthcare decisions and can assist the healthcare provider in involving the appropriate person in the care planning process.
Correct Answer is C
Explanation
A) Incorrect- Furosemide is a loop diuretic used to treat conditions such as edema and hypertension. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
B) Incorrect- Low-dose aspirin is often used for its antiplatelet effects to prevent cardiovascular events. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
C) Correct- Allopurinol is a medication used to treat gout by reducing the production of uric acid in the body. However, allopurinol can also increase the risk of forming calcium oxalate kidney stones, which is the type of kidney stone mentioned in the client's history. Calcium oxalate stones are the most common type of kidney stone, and they are composed primarily of calcium and oxalate. In this case, the client has a history of gout and is prescribed allopurinol. The nurse should bring the client's prescription for allopurinol to the healthcare provider's attention because
it has the potential to contribute to the formation of kidney stones, which could exacerbate the client's existing condition.
D) Incorrect- Enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and heart failure. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.
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