A nurse in an emergency department (ED) is caring for a client
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for correct choices:
- Hyperthyroidism: The client presents with classic signs of hyperthyroidism or thyroid storm: heat intolerance, tremors, tachycardia, palpitations, agitation, insomnia, weight loss despite good appetite, diarrhea, and recent illness (influenza) acting as a trigger. These symptoms indicate an acutely increased metabolic state.
- Place client on telemetry: Tachycardia and palpitations suggest cardiac involvement. Continuous cardiac monitoring helps detect life-threatening arrhythmias, such as atrial fibrillation, which are common in hyperthyroid crises.
- Initiate hydration therapy: Hypermetabolism, fever, and diarrhea can cause fluid loss and increase the risk for dehydration. Hydration supports perfusion and reduces cardiac strain during a hypermetabolic state.
- Cardiac dysrhythmias: Excess thyroid hormones increase the heart's sensitivity to catecholamines, heightening the risk for dysrhythmias. Monitoring rhythm helps identify complications early.
- Neurological status: Agitation, tremors, and insomnia may progress to delirium or seizures in thyroid storm. Regular neuro checks allow early recognition of worsening symptoms.
Rationale for incorrect choices:
- Hypoparathyroidism: This typically presents with signs of hypocalcemia such as tetany or paresthesias, not the metabolic hyperactivity seen here. The client's symptoms do not reflect this condition.
- Hyperparathyroidism: It usually causes hypercalcemia, bone pain, and kidney stones, none of which are evident. Diarrhea, fever, and cardiac signs are not typical.
- Hypothyroidism: Presents with fatigue, cold intolerance, constipation, bradycardia, and weight gain—opposite of this client’s hyperactive symptoms.
- Check for Chvostek and Trousseau’s signs: These are used to assess for hypocalcemia, which is not indicated in this scenario. There are no neuromuscular irritability symptoms present.
- Monitor for hypoglycemia: There's no indication of low blood sugar, and the client does not report symptoms like shakiness, confusion, or hunger related to hypoglycemia.
- Provide nutritional support: While the client has lost weight, the priority is stabilizing the acute condition (thyroid storm), not nutritional rehabilitation at this moment.
- Phosphorus levels: These are not directly affected in hyperthyroidism and monitoring them wouldn't provide information relevant to the current crisis.
- Weight gain: This client has experienced weight loss, and tracking weight gain is not a relevant short-term indicator of improvement in acute hyperthyroidism.
- Calcium levels: There is no evidence of calcium imbalance or parathyroid involvement, so monitoring calcium is not pertinent in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ensure the door to the client's room remains open: The door should be kept closed to minimize exposure to radiation. Keeping the door open increases the risk of radiation exposure to others in the area.
B. Wear sterile gloves during patient care: Sterile gloves are not required for care during internal radiation therapy unless there is direct contact with bodily fluids or radioactive materials. Standard precautions are sufficient.
C. Wear a lead apron when providing client care: A lead apron is recommended for healthcare workers to protect themselves from radiation exposure during internal radiation therapy. The lead apron absorbs radiation and helps reduce the risk of harmful exposure.
D. Place a dosimeter on the client's gown: The dosimeter is typically worn by healthcare workers to measure radiation exposure, not the client. The client would not wear a dosimeter in this situation.
Correct Answer is B
Explanation
A. Have the client identify stressful situations: While identifying stressful situations is important for stress management, it is not a specific treatment method for fibromyalgia. Stress reduction is part of management but is not the primary intervention for chronic pain.
B. Encourage the client to participate in yoga: Yoga is an excellent alternative treatment for fibromyalgia and chronic pain. It helps improve flexibility, reduce stress, and promote relaxation. It has been shown to improve pain, sleep, and quality of life for individuals with fibromyalgia.
C. Instruct the client to limit visitors: Limiting visitors is not a standard recommendation for treating fibromyalgia. Social support can be beneficial for emotional well-being, and there is no evidence suggesting that limiting social interactions improves fibromyalgia symptoms.
D. Advise the client to take walks regularly: Light physical activity like walking can be helpful for overall health. While walking can be part of an overall exercise plan, yoga is more directly beneficial for chronic pain in fibromyalgia.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.