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 ["A","C"]
Explanation
Rationale:
• Naloxone: The client received fentanyl and is now showing signs of opioid-induced respiratory depression. Respiratory rate has decreased to 10/min and oxygen saturation to 87%. Naloxone will reverse the opioid’s effects and restore adequate respiratory effort.
• An additional dose of propofol: The client’s level of sedation is already too deep, as shown by low respiratory rate and blood pressure. Additional propofol would worsen central nervous system depression. It may cause complete apnea or cardiac compromise in this situation.
• Oxygen 10 L/min via face mask: The current oxygen flow via nasal cannula is insufficient given the client's low oxygen saturation. A face mask delivers higher oxygen concentration and flow. This is critical to correct hypoxia until the cause is reversed.
• Acetaminophen: There is no fever or current complaint of pain requiring antipyretics or analgesics. Administering acetaminophen now would not address the acute respiratory issue. It would delay more urgent and appropriate interventions.
• An additional dose of fentanyl: Administering more opioid would increase the risk of further respiratory depression. The client is already showing hypoventilation and declining oxygenation. More fentanyl would worsen sedation and endanger airway and breathing.
• Propranolol: The client is already hypotensive with a BP of 80/51 mm Hg and a heart rate of 68/min. Giving a beta blocker could severely depress cardiac output. This would increase the risk of organ hypoperfusion and cardiac arrest.
Correct Answer is D
Explanation
Rationale:
A. New onset of hearing loss: Hearing loss is not a typical adverse effect of 0.9% sodium chloride infusion. It may occur with high-dose loop diuretics like furosemide but is unrelated to isotonic fluid administration or hyperparathyroidism management.
B. Kussmaul respirations: These are deep, rapid respirations seen in metabolic acidosis, particularly diabetic ketoacidosis. They are not associated with isotonic fluid infusion or calcium disturbances in hyperparathyroidism.
C. Hyperthermia: Elevated body temperature is not linked to 0.9% sodium chloride infusion. Hyperthermia may occur with infections or neurologic injury, but not as a direct consequence of isotonic fluid therapy.
D. Chvostek's sign: Chvostek's sign is a clinical indicator of hypocalcemia, which can occur as an adverse effect of 0.9% sodium chloride infusion in clients with hyperparathyroidism. Large volumes of saline increase calcium excretion, potentially leading to low serum calcium levels.
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