A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?
Cold and dry skin.
Facial puffiness and periorbital edema.
Hematocrit of 30% (0.30 volume fraction).
Further decline in the level of consciousness.
The Correct Answer is D
Choice A rationale
Cold and dry skin can be a symptom of hypothyroidism, but it’s not typically a sign that requires immediate action.
Choice B rationale
Facial puffiness and periorbital edema can be symptoms of hypothyroidism, but they’re not typically signs that require immediate action.
Choice C rationale
A hematocrit of 30% (0.30 volume fraction) is lower than the normal range, indicating anemia. While this is a concern and should be addressed, it’s not typically a sign that requires immediate action in the context of hypothyroidism.
Choice D rationale
A further decline in the level of consciousness can be a serious sign of deteriorating health in a client with hypothyroidism and should be acted upon immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An ABO incompatibility reaction can occur if a patient receives the wrong type of blood during a blood transfusion. Symptoms of an ABO incompatibility reaction include lower back pain and hypotension, which are serious and should be reported immediately to the healthcare provider.
Choice B rationale
A delayed painful rash with urticaria is not typically a symptom of an ABO incompatibility reaction. While it could indicate an allergic reaction, it is not as immediate or potentially life-threatening as the symptoms in Choice A1.
Choice C rationale
Acute rhinitis and nasal stuffiness are more commonly associated with respiratory infections, not ABO incompatibility reactions. These symptoms are not typically a direct result of a blood transfusion.
Choice D rationale
Arthritic joint changes and chronic pain are not associated with ABO incompatibility reactions. These symptoms are more likely related to long-term conditions like arthritis.
Correct Answer is C
Explanation
Choice A rationale
A CT scan of the chest can be performed to detect the severity of infection in pneumonia. However, it is not typically the first diagnostic test prescribed. It is usually recommended if the pneumonia isn’t clearing as quickly as expected.
Choice B rationale
Arterial blood gases (ABG) can be used to measure the oxygen level in your blood. Pneumonia can prevent your lungs from moving enough oxygen into your bloodstream. However, ABG is not typically the first diagnostic test prescribed for pneumonia.
Choice C rationale
A sputum culture test is often used to confirm the cause of infection in pneumonia. This test involves taking a sample of fluid from your lungs (sputum) after a deep cough and analyzing it to help pinpoint the cause of the infection.
Choice D rationale
Blood cultures can identify the germ causing your pneumonia and also show whether a bacterial infection has spread to your blood. However, they are not typically the first diagnostic test prescribed for pneumonia.
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