A client with hyperthyroidism tells the home health nurse, "I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding." Which assessment is most important for the nurse to obtain?

Peripheral pulses.

Vital signs.

Presence of goitre.

Emotional status.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing peripheral pulses is important for understanding the client's overall circulatory status, but it is not the most urgent assessment in this situation. The client's symptoms suggest a possible thyrotoxic crisis, which requires immediate evaluation of critical vital signs.

Choice B reason: Obtaining vital signs is the most important initial assessment. The client's report of anxiety, heart racing, and pounding could indicate a severe exacerbation of hyperthyroidism, potentially leading to a thyrotoxic crisis (thyroid storm). Vital signs will provide essential information on the client's heart rate, blood pressure, temperature, and overall stability, which are crucial for immediate management.

Choice C reason: The presence of a goitre can indicates thyroid gland enlargement, which is relevant for long-term management of hyperthyroidism. However, it does not provide immediate information on the client's current acute condition.

Choice D reason: Assessing emotional status is important for comprehensive care, but it is not the priority in this acute scenario. The client's physiological status needs to be stabilized first, as indicated by their vital signs, before focusing on their emotional state.

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Correct Answer is A

Explanation

Choice A reason: Describing the use of an elimination diet to find trigger foods is appropriate for clients with Crohn's disease. This approach helps identify specific foods that may cause or exacerbate symptoms, allowing the client to avoid them and manage their condition more effectively.

Choice B reason: Instructing the client to avoid foods with gluten is not necessary unless they have a confirmed gluten intolerance or celiac disease. Gluten avoidance is not a standard dietary restriction for Crohn's disease.

Choice C reason: Advising the client to limit foods that are high in calcium and iron is not appropriate, as these nutrients are important for overall health. Crohn's disease patients may need to adjust their diet based on individual needs and deficiencies, but blanket limitations on calcium and iron are not recommended.

Choice D reason: Explaining that the need to restrict fluids is the primary limitation is incorrect. In fact, staying well-hydrated is crucial for managing Crohn's disease. Fluid restriction may be necessary in specific cases, but it is not a general guideline.

A. Client denies urinary frequency, urgency, or dysuria. B. Stone fragments are collected when straining the client's urine. C. Urine is pale pink with no observable blood clots. D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

Correct Answer is B

Explanation

Choice A reason: Denial of urinary frequency, urgency, or dysuria is a good sign of symptom relief but does not directly confirm the success of the lithotripsy in terms of stone removal.

Choice B reason: The presence of stone fragments in the urine after lithotripsy indicates that the procedure successfully broke up the kidney stones, allowing them to be excreted. This is a direct and specific measure of the procedure's effectiveness.

Choice C reason: Pale pink urine with no observable blood clots is a positive sign and suggests that there is no significant bleeding, but it does not directly confirm the removal of the kidney stones.

Choice D reason: Normal serum creatinine and blood urea nitrogen (BUN) levels indicate good kidney function but do not specifically reflect the success of the lithotripsy in breaking up and removing the stones.

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A client with hyperthyroidism tells the home health nurse, "I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding." Which assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Correct Answer is A

Explanation

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Correct Answer is B

Explanation

A client who is postmenopausal, obese, and is a smoker, has developed an intolerance to fatty foods and believes she is at risk for developing gallbladder problems. Which instruction should the nurse provide to help reduce the client's risk for gallbladder disease?

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

The chest x-ray for a client who is admitted for pneumonia shows a pleural effusion with decreased air flow in the entire left upper lobe. After auscultating the left upper lobe, which breath sounds documented by the nurse verify the x-ray findings?

A client with peptic ulcer disease (PUD) is admitted to the medical unit. Which assessment finding requires the most immediate intervention by the nurse?

A client with chronic venous insufficiency is being discharged from the hospital and plans to return home. Which client statement indicates an understanding of home care instructions?

The nurse is teaching a client with gastritis about self-management. Which statement made by the client should the nurse recognize as needing additional education?

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?