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 A
Explanation
Regular weighing is an essential self-management strategy for clients with heart failure (HF). It helps monitor changes in fluid balance, which is crucial in managing HF symptoms. Sudden weight gain may indicate fluid retention, a worsening of HF, or the need for adjustments in medications or dietary restrictions. Daily weighing provides valuable information for both the client and healthcare provider to assess the effectiveness of the HF management plan.
While performing range of motion exercises and maintaining mobility are important for overall health, they may not be specifically related to the management of heart failure. The focus of discharge teaching for HF is typically on monitoring symptoms, medication management, diet and fluid restrictions, and when to seek medical attention.
Limiting fluid intake to 1,500 mL daily may be a general recommendation for some clients with HF, but it is best to individualize fluid restrictions based on the client's specific needs. The client should follow the fluid restriction prescribed by their healthcare provider, which may vary depending on the severity of HF and other individual factors.
While maintaining a balanced diet, including adequate protein intake, is important for overall health, there may be specific dietary recommendations for clients with HF that go beyond a general instruction to eat a high protein diet. Dietary instructions for HF clients typically include sodium restriction, fluid restriction if necessary, and considerations for comorbidities and medications.
Correct Answer is ["1.3"]
Explanation
1. Convert the infant's weight from pounds to kilograms. We can use the conversion factor 1 kg
= 2.2 lb. So, 22 lb x (1 kg / 2.2 lb) = 10 kg.
2. Calculate the total daily dose of amoxicillin for the infant. We can use the formula D = d x W, where D is the total daily dose, d is the dose per kg per day, and W is the weight in kg. So, D = 20 mg x 10 kg = 200 mg.
3. Calculate the single dose of amoxicillin for the infant. We can divide the total daily dose by the number of doses per day. Since the prescription is for every 8 hours, there are 3 doses per day. So, 200 mg / 3 = 66.67 mg.
4. Calculate the volume of amoxicillin suspension for the single dose. We can use the ratio of the concentration of the suspension, which is 250 mg per 5 mL. So, 66.67 mg x (5 mL / 250 mg) =
1.33 mL.
5. Round the volume to the nearest tenth= 1.3 mL
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