A nurse is assisting with the plan of care for a client who has hypothyroidism with myxedema. Which of the following interventions should the nurse include in the plan of care?

Place the client on bedrest.

Apply warm blankets.

Check the client for weight loss.

Limit high-fiber foods.

Answer and Explanation

The Correct Answer is B

Choice A: Place the client on bedrest. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Placing the client on bedrest can increase the risk of complications such as thromboembolism, pressure ulcers, and muscle atrophy. The nurse should encourage the client to perform gentle exercises and change positions frequently.

Choice B: Apply warm blankets. This is an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Hypothyroidism is a condition that occurs when the thyroid gland does not produce enough thyroid hormone. Thyroid hormone regulates the metabolism of carbohydrates, proteins, and fats, and aﬀects the energy expenditure and body temperature. Myxedema is a severe form of hypothyroidism that causes swelling of the skin and tissues due to accumulation of mucopolysaccharides. Applying warm blankets can help maintain the client’s body temperature and prevent hypothermia, which is a low body temperature.

Choice C: Check the client for weight loss. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Checking the client for weight loss can indicate hyperthyroidism, which is a condition that occurs when the thyroid gland produces too much thyroid hormone.

Hyperthyroidism can cause weight loss due to increased metabolic rate and appetite. The nurse should check the client for weight gain, which can indicate hypothyroidism due to decreased metabolic rate and ﬂuid retention.

Choice D: Limit high-fiber foods. This is not an intervention that the nurse should include in the plan of care for a client who has hypothyroidism with myxedema. Limiting high-fiber foods can cause constipation, which can worsen hypothyroidism symptoms such as bloating, abdominal pain, and fatigue. The nurse should encourage the client to eat high-fiber foods, such as fruits, vegetables, and whole grains, to promote bowel regularity and prevent constipation.

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Correct Answer is C

Explanation

Choice A: Obtain the client’s vital signs. This is an important nursing action, but not the priority. The nurse should monitor the client’s vital signs for signs of infection, ﬂuid imbalance, or shock, but these are not as urgent as relieving the client’s pain.

Choice B: Weigh the client. This is a necessary nursing action, but not the priority. The nurse should weigh the client daily to assess their ﬂuid status and nutritional needs, but this can be done after addressing the client’s pain.

Choice C: Administer pain medication. This is the priority nursing action because the nurse should follow the principle of Maslow’s hierarchy of needs and address the client’s physiological needs first. Pain can interfere with the client’s healing process and aﬀect their quality of life.

Choice D: Change the client’s dressing. This is a required nursing action, but not the priority. The nurse should change the client’s dressing to prevent infection and promote wound healing, but this can be done after administering pain medication to make the procedure more comfortable for the client.

A. Weak pulse B. Dark colored stools C. Spider angioma D. Increased body hair

Correct Answer is C

Explanation

Choice A: Weak pulse. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. A weak pulse may indicate hypovolemia, shock, or cardiac dysfunction, but it is not directly related to liver disease.

Choice B: Dark colored stools. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. Dark colored stools may indicate bleeding in the upper gastrointestinal tract, such as from esophageal varices or peptic ulcers, but they are not specific to liver disease.

Choice C: Spider angioma. This is a manifestation that the nurse should expect to find in a client who has advanced cirrhosis, which is a chronic liver disease that causes scarring and impaired liver function. Spider angioma is a type of vascular lesion that appears as a red spot with radiating branches on the skin, usually on the face, neck, chest, or upper arms. It is caused by increased estrogen levels due to reduced liver metabolism of hormones.

Choice D: Increased body hair. This is not a manifestation that the nurse should expect to find in a client who has advanced cirrhosis. Increased body hair may indicate hypertrichosis, which is excessive hair growth due to genetic, hormonal, or metabolic factors, but it is not related to liver disease.

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A nurse is assisting with the plan of care for a client who has hypothyroidism with myxedema. Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurse expect to find?

Correct Answer is C

Explanation

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