A client who has a history of hypothyroidism was admitted with lethargy and confusion. Which additional finding warrants immediate action by the nurse?

Haematocrit of 30% (0.30 volume fraction).

Facial puffiness and periorbital enema.

Further decline in level of consciousness.

Cold and dry skin.

Answer and Explanation

The Correct Answer is C

Choice A reason: A haematocrit of 30% is below the normal range and indicates anaemia, which is common in hypothyroidism. However, it does not require immediate intervention compared to a decline in consciousness.

Choice B reason: Facial puffiness and periorbital enema are common signs of hypothyroidism but do not require immediate intervention. They are more indicative of chronic, rather than acute, issues.

Choice C reason: A further decline in level of consciousness is critical and warrants immediate action. It can indicate a myxoedema coma, a severe complication of hypothyroidism that is life-threatening and requires urgent treatment.

Choice D reason: Cold and dry skin is a common symptom of hypothyroidism but does not require immediate intervention compared to a decline in consciousness.

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Correct Answer is B

Explanation

Choice A reason: Amber urine is not unusual and can be related to dehydration. Although it should be monitored, it is not the most urgent finding in this scenario.

Choice B reason: Yellow sclera is a sign of jaundice, which occurs when there is a significant buildup of bilirubin in the blood. This is a critical indicator of a blocked bile duct and requires immediate medical attention to prevent severe complications.

Choice C reason: Flatulence is common with gastrointestinal disturbances but is not an urgent finding compared to jaundice.

Choice D reason: Belching is also common in digestive disorders and not as concerning as the presence of jaundice, which indicates a potentially serious problem with bile drainage.

A. Elevate the head of the bed to 90 degrees. B. Monitor pulse oximetry every 2 hours. C. Determine exposure to asthmatic triggers. D. Teach proper use of a rescue inhaler.

Correct Answer is A

Explanation

Choice A reason: Elevating the head of the bed to 90 degrees is crucial for clients in respiratory distress. This position helps to maximize lung expansion, improve breathing, and alleviate respiratory effort. It provides immediate support to enhance oxygenation and ventilation.

Choice B reason: Monitoring pulse oximetry is important for assessing the client's oxygenation status but should be done continuously rather than every 2 hours in a client in respiratory distress.

Choice C reason: Determining exposure to asthmatic triggers is relevant for long-term management but not the immediate priority in an acute situation where the client is in respiratory distress.

Choice D reason: Teaching the proper use of a rescue inhaler is essential but should be done after stabilizing the client's condition. The immediate focus should be on interventions that provide rapid relief from respiratory distress.

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