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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Obtaining a sputum sample is important for diagnosing respiratory infections, but it is not the priority intervention in this case. The patient’s symptoms of intermittent fever, night sweats, and a productive cough with small amounts of blood are indicative of a possible airborne disease such as tuberculosis.
Choice B rationale
Arranging transport for radiographic imaging can be helpful in diagnosing the patient’s condition, but it is not the immediate priority. The primary concern should be to prevent the potential spread of an airborne disease.
Choice C rationale
Moving the patient into airborne isolation is the priority intervention. This action is taken to prevent the spread of potential airborne diseases to other patients and healthcare workers.
Choice D rationale
Collecting specimens for blood cultures can help identify the causative organism if the patient has a systemic infection. However, given the patient’s symptoms and the potential for an airborne disease, moving the patient into isolation is the priority.

A. Computerized tomography (CT) of the chest. B. Arterial blood gases (ABG). C. Sputum culture and sensitivity. D. Blood cultures.

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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A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse’s priority intervention?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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