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 B
Explanation
Choice A rationale
Limiting intake of oral fluids is not typically recommended for a client with urinary retention related to sensorimotor deficits in multiple sclerosis. Adequate hydration is important for overall health and can help prevent urinary tract infections14.
Choice B rationale
Teaching the client techniques for performing intermittent catheterization is a common and effective strategy for managing urinary retention in multiple sclerosis. This can help the client maintain independence and improve quality of life14.
Choice C rationale
While pelvic floor (Kegel) exercises can help strengthen the muscles involved in urination, they may not be sufficient to manage urinary retention in a client with multiple sclerosis.
Intermittent catheterization (Choice B) is often more effective14.
Choice D rationale
Providing a bedside commode can be helpful for a client with mobility issues, but it does not directly address the issue of urinary retention in multiple sclerosis14.
Correct Answer is ["125"]
Explanation
Step 1 is to convert the volume of the prescription from liters to milliliters. 1 liter is equal to 1000 mL. So, the prescription is for 1000 mL of lactated Ringer’s.
Step 2 is to divide the total volume by the total time. The prescription is to be infused over 8 hours. So, 1000 mL ÷ 8 hours = 125 mL/hr. Therefore, the nurse should program the infusion pump to deliver 125 mL/hr.
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