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

Facial puffiness and periorbital edema.

Cold and dry skin.

Further decline in level of consciousness.

Hematocrit of 30% (0.30).

Answer and Explanation

The Correct Answer is C

A. Facial puffiness and periorbital edema:
These are common signs of hypothyroidism but may not require immediate action unless accompanied by severe symptoms.

B. Cold and dry skin:
Cold and dry skin is a characteristic feature of hypothyroidism, but a further decline in the level of consciousness is a more urgent issue.

C. Further decline in the level of consciousness.
A decline in the level of consciousness is a critical sign that requires immediate attention, as it may indicate worsening hypothyroidism, myxedema coma, or other serious complications. Myxedema coma is a life-threatening condition associated with severe hypothyroidism, and it requires prompt medical intervention.

D. Hematocrit of 30% (0.30):
While anemia is a potential complication of hypothyroidism, a hematocrit of 30% alone may not be the most immediate concern compared to a decline in the level of consciousness.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Minimize symptoms by wearing loose, comfortable clothing:
This is the correct answer. Wearing loose, comfortable clothing can help alleviate pressure on the abdomen, reducing the likelihood of exacerbating GERD symptoms.

B. Sleep without pillows at night to maintain neck alignment:
This recommendation is not specifically related to GERD. In fact, elevating the head of the bed or using extra pillows can be helpful in preventing acid reflux during sleep.

C. Adjust food intake to three full meals per day and no snacks:
It is generally recommended for individuals with GERD to have smaller, more frequent meals rather than three large meals. Eating smaller portions can help reduce the likelihood of gastric distention and reflux.

D. Avoid participation in any aerobic exercise programs:
Exercise is generally beneficial for overall health, but intense aerobic exercise immediately after eating may contribute to GERD symptoms. However, this does not mean avoiding all aerobic exercise. It is more appropriate to advise against vigorous exercise immediately after meals.

A. Assess client for signs and symptoms of upper airway infection. B. Determine if the client is using an inhaler before exercising. C. Teach client to use pursed lip breathing when episodes occur. D. Review the client's routine asthma management prescriptions

Correct Answer is D

Explanation

A. Assess client for signs and symptoms of upper airway infection:
While upper airway infections can contribute to respiratory symptoms, the client's history of asthma and the exacerbation of symptoms during exercise suggest that asthma management should be a priority.

B. Determine if the client is using an inhaler before exercising:
This is a relevant consideration, and ensuring proper pre-exercise use of bronchodilators (such as an inhaler) is an important aspect of asthma management. However, the question is broader and involves a review of the client's overall asthma management.

C. Teach client to use pursed lip breathing when episodes occur:
Pursed lip breathing is a technique that can help manage symptoms, especially during episodes of bronchoconstriction. However, the focus here is on a more comprehensive assessment and review of the client's routine asthma management.

D. Review the client's routine asthma management prescriptions:
This is the correct answer. The client's reported symptoms during exercise suggest a potential need for adjustments to the routine asthma management plan. Reviewing the client's prescriptions, including the type and timing of medications, can help ensure optimal control of symptoms, especially during physical activity.

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

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