A nurse is caring for a client who has chronic hypothyroidism. For which of the following conditions should the nurse monitor?
Photophobia
Exophthalmos
Lethargy
Goiter
The Correct Answer is C
A. Photophobia is not typically associated with hypothyroidism. It can be a symptom of conditions affecting the eyes, such as certain infections or ocular disorders.
B. Exophthalmos is a protrusion of the eyeballs and is a characteristic symptom of hyperthyroidism (overactive thyroid), not hypothyroidism (underactive thyroid).
C. Correct. Lethargy is a common symptom of hypothyroidism. It is characterized by extreme tiredness, sluggishness, and lack of energy.
D. Goiter is an enlargement of the thyroid gland and can occur in both hyperthyroidism and hypothyroidism. However, it is not a direct symptom; it is a physical finding that can be associated with thyroid disorders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Serum potassium 2.5 mEq/L and blood pressure 150/90 mmHg - This combination of severe hypokalemia (low potassium) and elevated blood pressure is a concerning finding. It can lead to serious cardiac complications and requires immediate attention.
B. Serum phosphorus 3 mg/dL and hirsutism - While low serum phosphorus may be seen in Cushing syndrome, it is not an immediate concern. Hirsutism (excessive hair growth) is a characteristic feature of Cushing syndrome.
C. Serum calcium 10 mg/dL, and reports of feelings of depression - Although an elevated serum calcium level is not typical in Cushing syndrome, it is not an immediate concern. Reports of depression should be addressed but do not require immediate follow-up.
D. Serum sodium 145 mEq/L and reports of muscle weakness - These findings are not indicative of immediate danger. Elevated serum sodium and muscle weakness can occur in Cushing syndrome, but they do not warrant immediate attention compared to the potassium level and blood pressure in option A.
Correct Answer is D
Explanation
A. Administering aspirin for hyperthermia is not a standard intervention for hyperthyroidism. Hyperthermia can occur in severe cases of hyperthyroidism, but the primary intervention is to address the underlying thyroid dysfunction and provide supportive care.
B. Keeping the client NPO (nothing by mouth) is not directly related to preventing a thyroid crisis in hyperthyroidism. It may be necessary for certain pre-operative preparations or if the client is undergoing specific procedures, but it does not address the prevention of a thyroid crisis.
C. While monitoring for signs of hypocalcemia is important in some cases of thyroid dysfunction, it is not the primary action to prevent a thyroid crisis. In hyperthyroidism, the focus is on managing excessive thyroid hormone levels.
D. Correct. Providing a quiet, low-stimulus environment is a crucial nursing intervention for clients with hyperthyroidism. They can be highly sensitive to external stimuli due to their increased metabolic rate. A calm environment helps reduce stress and the risk of exacerbating symptoms, potentially preventing a thyroid crisis.
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