A nurse is assisting with the care of a client in a provider's clinic.
The client presents to clinic reporting a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well.
Oriented x 4. Answers questions appropriately, follows simple commands. Heart rate regular, S1 S2 auscultated. No abnormal heart sounds heard. Respiration even and unlabored. Lung sounds clear to auscultation. Abdomen soft, flat, normoactive bowel sounds in all four quadrants. Client states, "appetite is good" and stools are soft and brown.
Reports voiding without difficulty, clear yellow urine.
Reports last menstrual period was 3 months ago.
Skin is warm and moist. Exophthalmos noted, goiter visualized on neck.
Client's partner reports that the client is irritable and anxious lately.
Correct Answer : A,D,E,F
Rationale:
• 3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and insomnia: These symptoms are consistent with hypermetabolic activity seen in hyperthyroidism, particularly Graves’ disease, and require follow-up and management to prevent complications like thyroid storm.
• Last menstrual period was 3 months ago: Amenorrhea can occur due to hormonal imbalance caused by elevated thyroid hormones. This finding indicates endocrine dysfunction and should be investigated further.
• Skin is warm and moist. Exophthalmos noted, goiter visualized on neck: These are classic physical signs of Graves’ disease, an autoimmune hyperthyroid condition. The exophthalmos (protruding eyes) and goiter (thyroid enlargement) are abnormal and require follow-up.
• Client's partner reports that the client is irritable and anxious lately: Mood changes, such as irritability and anxiety, are common in hyperthyroidism and may affect the client’s quality of life and safety. This finding warrants further psychological and endocrine evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Heparin 5000 U subcutaneous every 8 hr: Using "U" for units can be misread as zero, potentially causing a tenfold overdose. The correct transcription uses the full word "units" to prevent errors.
B. M50, 10g PO delly: This prescription contains multiple errors: "M50" is unclear, "10g" may be excessive or incorrect dosing, and "delly" is an incorrect abbreviation for daily. This transcription is inaccurate and unsafe.
C. Lorazepam 0.5 mg PO PRN at bedtime: Although mostly correct, "PRN at bedtime" can be confusing. It is clearer to specify "PRN for anxiety at bedtime" or "PRN as needed at bedtime" to clarify the indication and timing.
D. Doxazosin 5 mg PO at bedtime: This transcription is clear, uses accepted abbreviations, specifies route and time, and includes no dangerous abbreviations, making it an accurate and safe prescription transcription.
Correct Answer is A
Explanation
Rationale:
A. "Discontinue the medication. I will ask your provider for another antibiotic.": Calf pain in a client taking ciprofloxacin may indicate tendinitis or even tendon rupture, a serious adverse effect associated with fluoroquinolones. The nurse should advise discontinuation of the drug and alert the provider immediately to prevent permanent damage.
B. "That reaction means your dose is too high. Cut the pill in half.": Reducing the dose without provider approval is unsafe and does not address the underlying risk of tendon injury. Ciprofloxacin-related tendinopathy is not dose-dependent and requires immediate discontinuation.
C. "Continue to take the medication. Calf pain is a minor reaction that will resolve itself.": Calf pain during ciprofloxacin therapy should never be dismissed as minor, since it may signal tendon inflammation or rupture.
D. “This is an allergic reaction. Take the medication with an antihistamine.": Tendon-related adverse effects are not allergic reactions and will not respond to antihistamines. Misclassifying the symptom as an allergy delays the proper intervention and increases the risk of irreversible tendon damage.
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