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 C

Explanation

Choice A reason: Notifying the charge nurse that the client will need assignment to the COVID-19 specified area of the facility is an important action for infection control. However, the most immediate priority is to protect oneself and others by maintaining appropriate distance and using PPE.

Choice B reason: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is necessary for safe specimen handling and to prevent contamination. While important, it follows after ensuring that proper PPE is used and distancing measures are maintained.

Choice C reason: Maintaining a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions is the most crucial action. This step ensures the nurse’s safety and reduces the risk of virus transmission. Proper PPE and distancing protocols are essential in managing a suspected COVID-19 case.

Choice D reason: Starting an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results is part of the treatment plan if the test comes back positive. However, this step comes after ensuring safety through proper use of PPE and maintaining distance from the client.

A. Decrease dietary fat intake. B. Increase fluids and dietary fibber. C. Ingest frequent small meals. D. Reduce roughage in the diet.

Correct Answer is D

Explanation

Choice A reason: Decreasing dietary fat intake can be beneficial for overall health, but it is not specifically related to managing diverticulitis. Dietary fat does not directly influence the inflammation of diverticula.

Choice B reason: Increasing fluids and dietary fibber is important for preventing diverticulosis, which is the presence of diverticula in the colon. However, during an acute episode of diverticulitis, high fibber can exacerbate symptoms. Therefore, this recommendation is not appropriate during active inflammation.

Choice C reason: Ingesting frequent small meals can aid in digestion and prevent large meals from causing discomfort, but it does not directly address the dietary needs during diverticulitis.

Choice D reason: Reducing roughage in the diet is crucial during an acute episode of diverticulitis. High-fibber foods and roughage can irritate the inflamed diverticula and worsen symptoms. A low-fibber diet is often recommended until the inflammation subsides, after which a gradual return to a high-fibber diet can be beneficial to prevent future episodes.

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

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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