A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

"My parent has type 2 diabetes mellitus."

"I wish my family was more supportive of my decision."

"I am not very good about taking prescribed medication."

"I had symptoms of asthma when I was a child."

Answer and Explanation

The Correct Answer is C

C. This is crucial because good medication adherence is essential for a transplant recipient to prevent rejection and maintain overall health. Non-adherence can jeopardize the transplant's success.

A This could be a risk factor for the client's own health, but it's not directly related to the transplant process or medication adherence.

B. This highlights a psychosocial concern, important for overall well-being, but doesn't directly impact the transplant candidacy.

D. This might be relevant for the medical history, but it doesn't directly affect medication adherence or the immediate transplant candidacy (unless the asthma is severe and uncontrolled).

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Correct Answer is A

Explanation

A Hyperthermia is a hallmark sign of thyroid storm due to the body's increased metabolic rate and inability to dissipate heat efficiently. High fever is a critical sign that should prompt immediate medical evaluation and treatment.

B. While fatigue and lethargy can occur in hyperthyroidism, they are not prominent features of thyroid storm. Individuals with thyroid storm typically exhibit agitation, restlessness, or even delirium due to the effects of excessive thyroid hormone on the central nervous system.

C. Bradycardia is not a feature of thyroid storm. Instead, individuals typically experience severe tachycardia, which can lead to palpitations, chest pain, and cardiovascular complications.

D. Thyroid storm is more commonly associated with hypertension rather than hypotension. Increased cardiac output and vascular resistance contribute to elevated blood pressure during thyroid storm.

A. Turn off all lights in the client's room at night. B. Assist the client with toileting at least once every 4 hr. C. Place the client's bed at the lowest height. D. Request a prescription for a nightly sedative.

Correct Answer is C

Explanation

C. Lowering the bed height reduces the risk of injury in case the client falls out of bed. It also facilitates easier transfers for clients with mobility issues.

A Individuals with dementia may experience disorientation and confusion, especially in unfamiliar or dark environments. Turning off all lights can increase the risk of falls and accidents.

B. Clients with dementia may have difficulty recognizing the need to toilet or may forget where the bathroom is located. They may also have urinary or fecal incontinence. Scheduled toileting helps prevent accidents and promotes continence.

D. Sedatives or hypnotic medications can increase confusion, risk of falls, and adverse effects in older adults with dementia. They are generally not recommended as first-line treatment for sleep disturbances in dementia.

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A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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