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 B

Explanation

Choice A reason: Fluid volume excess is not related to the therapeutic use of galantamine hydrobromide. This medication is used to improve cognitive function in clients with Alzheimer's disease, which is more closely associated with disturbed thought processes.

Choice B reason: Disturbed thought processes are directly related to the therapeutic use of galantamine hydrobromide. This medication helps enhance cognitive function by increasing the levels of acetylcholine in the brain, which is crucial for memory and thinking. Clients with Alzheimer's disease often experience cognitive decline, and this medication aims to mitigate those symptoms.

Choice C reason: Altered breathing pattern is not addressed by the therapeutic use of galantamine hydrobromide. This medication is specifically used to treat cognitive symptoms associated with Alzheimer's disease, rather than respiratory issues.

A. Petechial haemorrhage under client's eyes. B. Right lower abdomen rebound tenderness. C. Severe headache with photosensitivity. D. Dark green coloured emesis.

Correct Answer is B

Explanation

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

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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

The nurse administers galantamine hydrobromide to a client with early onset Alzheimer's disease. Which nursing problem addresses its therapeutic use?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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