A nurse is assessing a patient admitted with hyperthyroidism.
The patient reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness.Which of the following actions should the nurse take to prevent a thyroid crisis?
Provide a quiet, low-stimulus environment
Keep the patient NPO
Administer aspirin as prescribed for any sign of hyperthermia.
Observe the patient carefully for signs of hypocalcemia.
The Correct Answer is A
Choice A rationale
Providing a quiet, low-stimulus environment is one of the key interventions for a patient with hyperthyroidism who is at risk of a thyroid crisis. Hyperthyroidism is characterized by an overproduction of thyroid hormones, which can accelerate the body’s metabolism causing symptoms such as rapid heart rate, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. A thyroid crisis, also known as a thyroid storm, is a severe, life-threatening condition characterized by extreme symptoms of hyperthyroidism. A quiet, low-stimulus environment can help reduce anxiety and agitation, which can exacerbate symptoms and potentially trigger a thyroid crisis.
Choice B rationale
Keeping the patient NPO (nothing by mouth) is not typically necessary in the management of hyperthyroidism unless the patient is preparing for a procedure such as thyroid surgery. In
fact, because of the increased metabolic rate in hyperthyroidism, patients often have an increased appetite and may require additional caloric intake.
Choice C rationale
Administering aspirin for any sign of hyperthermia is not recommended in hyperthyroidism. Aspirin can actually increase the level of free thyroid hormones in the blood by displacing them from their binding proteins, potentially worsening the hyperthyroid state.
Choice D rationale
While it is important to observe patients with hyperthyroidism for signs of various complications, hypocalcemia is not typically associated with hyperthyroidism. Hypocalcemia, or low calcium levels in the blood, is more commonly associated with hypoparathyroidism or vitamin D deficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Documenting the bowel sounds as hypoactive is not the most appropriate action. Hypoactive bowel sounds are fewer than three bowel sound events in a minute or none at all. However, the absence of bowel sounds does not necessarily mean they are hypoactive. It could be due to other reasons such as ileus.
Choice B rationale
Administering prescribed drugs for constipation is not the immediate course of action when the nurse doesn’t hear any gurgling while listening to bowel sounds. Constipation is a condition that can cause hypoactive bowel sounds, but it’s not the only reason for the absence of bowel sounds. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice C rationale
Reviewing dietary intake for the past 24 hours is not the immediate course of action. While diet can affect bowel sounds, it’s not the first step when bowel sounds are not heard. The nurse should first confirm the absence of bowel sounds before considering this action.
Choice D rationale
The correct action when the nurse doesn’t hear any gurgling while listening to bowel sounds is to continue to listen for at least another 60 seconds. Bowel sounds are produced by the movement of fluid, gas, and contents through the intestines. An absence of bowel sounds for greater than two minutes may indicate that there is no peristalsis—which implies an ileus.
Therefore, the nurse should continue to listen for at least another 60 seconds to confirm the absence of bowel sounds.
Correct Answer is ["A","D"]
Explanation
Choice A rationale
Hepatitis A is a highly contagious virus that spreads through person-to-person contact or consuming contaminated food or drink. The virus can contaminate food during growing, harvesting, processing, handling, and even after cooking. Therefore, avoiding serving raw foods can help prevent the spread of the virus.
Choice B rationale
Hepatitis A is not typically spread through sexual intercourse. It is primarily spread through the fecal-oral route, either by person-to-person contact or consumption of contaminated food or water. Therefore, wearing barrier protection during vaginal intercourse is not a primary prevention strategy for Hepatitis A.
Choice C rationale
While it’s possible to contract Hepatitis A from food prepared at any location, including fast food restaurants, the risk is not specifically associated with these establishments. The key is whether the food is contaminated with the virus, which can occur in any setting if food is handled by someone infected with Hepatitis A who doesn’t properly wash their hands after using the toilet.
Choice D rationale
Practicing effective hand hygiene, including thoroughly washing hands after using the bathroom, changing diapers, and before preparing or eating food, is a primary prevention strategy for Hepatitis A1. The virus is spread in part by the fecal-oral route, so good hand hygiene can help prevent ingestion of the virus.
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.
