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A nurse is assisting with the care of a client in a provider's clinic.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

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 ×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, fat, normoactive bowel sounds in all four quad 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. Exophthalmus noted, goiter visualized on neck. Client’s partner reports that the client is imitable and anxious lately.

a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well

Reports last menstrual period was 3 months ago

Exophthalmus noted, goiter visualized on neck. Client’s partner reports that the client is imitable and anxious lately

Abdomen soft, fat, normoactive bowel sounds in all four quad states

No abnormal heart sounds heard

Answer and Explanation

The Correct Answer is ["A","B","C"]

3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and difficulty sleeping: These symptoms are classic for hyperthyroidism and suggest worsening metabolic imbalance. They require follow-up because untreated hyperthyroidism can lead to serious complications like thyroid storm.
Reports last menstrual period was 3 months ago: Amenorrhea or menstrual irregularities are common in hyperthyroidism due to hormonal disruption. This finding supports the diagnosis and needs follow-up for endocrine and reproductive health management.
Exophthalmos noted: Exophthalmos, or bulging eyes, is associated with Graves' disease and indicates autoimmune involvement affecting the orbital tissues. It can lead to complications like corneal ulceration or vision loss if severe and thus requires ophthalmologic evaluation.
Goiter visualized on neck: A visible goiter reflects thyroid gland enlargement, often due to hyperstimulation from excess thyroid hormones. It requires ongoing monitoring to assess for airway compromise, dysphagia, or further gland enlargement.
Client’s partner reports irritability and anxiety: Behavioral and mood changes like irritability and anxiety are manifestations of hyperthyroidism affecting neurological function. Persistent symptoms can impair quality of life and must be addressed as part of comprehensive treatment planning.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.

B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.

C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.

D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.

A. Reviewing client education B. identifying problem-solving skills C. Summarizing the goals and objectives achieved D. Specifying a contract

Correct Answer is B

Explanation

A. Reviewing client education: Reviewing education is often part of the termination phase, where teaching is reinforced and the nurse ensures the client understands care plans after the therapeutic relationship ends. It is not a primary focus during the working phase.

B. Identifying problem-solving skills: The working phase focuses on active problem-solving, setting goals, and implementing strategies to address the client's issues. This is when trust is established further, and the nurse and client collaborate on interventions and coping techniques to promote positive outcomes.

C. Summarizing the goals and objectives achieved: Summarizing achievements is part of the termination phase, when the nurse and client reflect on progress made. It helps bring closure to the relationship but does not belong to the working phase where the focus is still on active progress.

D. Specifying a contract: Specifying a contract is a task of the orientation phase, where the structure of the nurse-client relationship, roles, and expectations are defined. This lays the foundation before entering into the problem-solving focus of the working phase.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

Correct Answer is A

Explanation

A nurse is discussing the components of the working phase of the nurse-client relationship with a client. Which of the following tasks are specific for this stage to create a therapeutic environment?

Correct Answer is B

Explanation

The nurse has reviewed the Graphic Record and Diagnostic Results at 1030. The nurse is collaborating with another nurse about the client's plan of care. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse is assisting with the plan of care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is assisting with the care of a client who is pregnant The nurse is reviewing the client's medical record. Select 4 findings that the nurse should identify as a potential prenatal complication.

A nurse is caring for a client who has a chlamydial infection and a new prescription for doxycycline. The client reports nausea and vomiting after starting the medication. Which of the following recommendations should the nurse make?

A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take?

A nurse is collecting data from a client who reports manifestations of depression. Which of the following findings should the nurse identify as a risk factor for suicide?

A nurse is documenting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?

A nurse is assisting in the discharge planning of an infant who has a spica cast. Which of the following equipment needs should the nurse identify for discharge?