A client whose hyperthyroidism has not been responsive to medications is admitted for evaluation. During the admission assessment the client reports to the nurse of a sudden onset of feeling apprehensive and nurse notes the client is restless and very warm to touch. Which action should the nurse implement next?
Access laboratory results to confirm a thyroid crisis.
Obtain a complete set of vital signs.
Initiate intravenous access.
Encourage relaxation and slow deep breathing.
The Correct Answer is C
In this scenario, the client's sudden onset of feeling apprehensive, restlessness, and increased body temperature are consistent with symptoms of a thyroid crisis, also known as thyroid storm or thyrotoxic crisis. Thyroid crisis is a life-threatening condition that requires immediate medical intervention.
Initiating IV access is crucial to ensure the prompt administration of medications and fluids to manage the thyroid crisis effectively. IV access allows for the administration of beta-blockers, antithyroid drugs, and supportive care, which are essential components of the treatment for thyroid crisis. IV access also provides a route for fluid resuscitation if necessary.
Accessing laboratory results to confirm a thyroid crisis is important, but the clinical presentation of the client with sudden onset symptoms and a known history of uncontrolled hyperthyroidism suggests the need for immediate intervention rather than waiting for laboratory confirmation.
Obtaining a complete set of vital signs is an important assessment to gather comprehensive data, but in the case of a suspected thyroid crisis, immediate intervention takes precedence over obtaining vital signs.
Encouraging relaxation and slow deep breathing may be beneficial in managing anxiety or discomfort, but it does not address the underlying emergency situation of a thyroid crisis. The nurse should focus on initiating appropriate medical interventions first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In this scenario, the child with a congenital heart defect is presenting with a fever and an
earache. The mother expresses concern about the child's weight and height being at the 5th percentile for his age. Given the child's medical history of a congenital heart defect, it is important for the nurse to address the mother's concerns and provide an accurate response.
The response that states "His smaller size is probably due to the heart disease" is appropriate because children with congenital heart defects may experience growth and developmental delays. Heart defects can affect the child's ability to obtain sufficient nutrients for growth, leading to slower weight and height gain. By acknowledging the relationship between the child's heart disease and his smaller size, the nurse provides the mother with an explanation for the child's growth pattern and helps alleviate concerns.
The other response options are not appropriate or helpful. Asking about the child's mental abilities or implying that the mother has not been feeding the child adequately can be perceived as judgmental or dismissive.
Correct Answer is C
Explanation
Clients with early-stage Alzheimer's disease may experience impaired judgment and cognitive decline, which can increase their risk for injury. Arranging the client's environment in a way that allows them to move about freely helps promote their safety and reduces the risk of accidents or falls.
Engaging the client in regularly scheduled activities during the day is a beneficial intervention as it provides structure and stimulation for the client. However, it may not directly address the risk for injury related to impaired judgment.
Offering the client frequent reassurance that they will be safe is important to provide emotional support, but it may not be sufficient in preventing physical harm or addressing the specific nursing problem of risk for injury.
Assigning a UAP (Unlicensed Assistive Personnel) to provide the client with total personal care may be helpful in assisting with activities of daily living. However, it does not directly address the risk for injury related to impaired judgment, and the nurse should have a central role in coordinating and overseeing the client's care.
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