A nurse is assisting with the care of a client in a provider's clinic.
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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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Temperature of 37.2° C (99.0° F): A temperature of 37.2° C is within the normal range and does not necessarily indicate infection. Mild temperature elevations are common in the immediate postoperative period due to inflammatory responses rather than infection, which typically presents with more significant fever.
B. Elevated WBC count: An elevated white blood cell (WBC) count is a classic and early indicator of infection. It reflects the body's immune response to a bacterial or viral invasion, and postoperative infections often present with leukocytosis, making it a key finding to monitor closely.
C. Pain rating of 4 on a scale of 0 to 10: Moderate pain is expected after surgery and does not, by itself, suggest infection. Postoperative pain should be assessed in context with other symptoms like redness, swelling, or drainage; pain alone, especially if stable, is not definitive for infection.
D. Increased urinary output: Increased urinary output is generally a positive sign of good kidney perfusion and hydration status. A decrease, not an increase, in urinary output would be more concerning postoperatively and could suggest complications, but not necessarily infection.
Correct Answer is D
Explanation
A. Increased senses: PCA pump use, typically involving opioids, does not heighten the senses. Instead, opioids often dull sensory perception and can cause sedation rather than making sensations sharper or more intense.
B. Decreased sleep: Opioids used in PCA pumps often promote drowsiness and sleep rather than reducing it. Sleep disturbances are not a common direct effect of properly managed PCA analgesia unless pain remains uncontrolled.
C. Difficulty swallowing: Difficulty swallowing is not a usual side effect associated with PCA use. If it occurs, it would likely suggest another issue, such as a neurological problem, rather than a typical reaction to PCA-administered opioids.
D. Urinary frequency: Opioids can affect the bladder by either causing urinary retention or, less commonly, altering normal patterns. Clients receiving adequate hydration and pain management might experience urinary frequency, especially as mobility increases postoperatively.
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