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. Allergy to penicillins: Penicillin allergies are important when prescribing beta-lactam antibiotics like amoxicillin, but azithromycin is not a penicillin; it belongs to the macrolide class, so this allergy is not directly relevant.
B. Allergy to macrolides: Azithromycin is a macrolide antibiotic. An allergy to macrolides must be reported immediately because administering azithromycin could trigger an allergic reaction, which could be serious or life-threatening.
C. Allergy to sulfonamides: Sulfonamide allergies are relevant when prescribing medications like sulfamethoxazole-trimethoprim, but azithromycin does not belong to the sulfonamide class.
D. Allergy to tetracyclines: Tetracyclines are a different class of antibiotics, used for infections such as acne or certain respiratory infections. An allergy to tetracyclines is not a concern when administering azithromycin.
Correct Answer is B
Explanation
A. Medication: The medication, erythromycin, is clearly stated and appropriately spelled. There is no confusion about what drug the provider intended to prescribe, so there is no immediate need to clarify the medication name itself.
B. Route: The prescription does not specify the route of administration, which is essential for safe medication delivery. Erythromycin can be given orally or intravenously, and using the wrong route could lead to serious complications. Clarifying the route ensures proper technique and absorption.
C. Dosage: The dosage of 500 mg is within the standard therapeutic range for erythromycin, depending on the severity and type of infection. Since the dose appears appropriate, it does not require immediate clarification unless clinical concerns arise.
D. Time: Although "four times per day" is broad, it is generally understood as approximately every six hours. While more exact times can improve consistency, missing the route of administration is a more critical and urgent issue to clarify for client safety.
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