A nurse is caring for a client who is immediately postoperative following a subtotal thyroidectomy.

Vital Signs

1100:

Temperature 37.4° C (99.4° F) Heart rate 98/min Respiratory rate 18/min

Blood pressure 128/68 mm Hg

Pulse oximetry 97% on room air

1115:

Temperature 37.8° C (100.1° F) Heart rate 110/min Respiratory rate 16/min

Blood pressure 138/74 mm Hg

Pulse oximetry 95% on room air

1130:

Temperature 38.6° C (101.5° F). Heart rate 136/min

Respiratory rate 16/min

Blood pressure 154/86 mm Hg

Pulse oximetry 95% on 2 L/min via nasal cannula

Select the 4 client findings that lead the nurse to suspect that the client is experiencing thyroid storm.

Mental status

Wound drainage

Heart rate

Pain

Blood pressure

Temperature

Answer and Explanation

Correct Answer : A,C,E,F

A. This choice is correct because mental status changes, such as agitation, confusion, or delirium, are common signs of thyroid storm, which is a life-threatening complication of hyperthyroidism that occurs when there is excessive release of thyroid hormones.

B. This choice is incorrect because wound drainage is not a specific sign of thyroid storm, but rather a potential complication of any surgery that can indicate infection or bleeding.

C. This choice is correct because tachycardia, or increased heart rate, is a common sign of thyroid storm, which can result from increased metabolic demand and increased sensitivity to catecholamines.

D. This choice is incorrect because pain is not a specific sign of thyroid storm, but rather a common symptom of any surgery that can be managed with analgesics.

E. This choice is correct because hypertension, or increased blood pressure, is a common sign of thyroid storm, which can result from increased cardiac output and peripheral vascular resistance.

F. This choice is correct because hyperthermia, or increased temperature, is a common sign of thyroid storm, which can result from increased heat production and impaired heat dissipation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:

Face is incorrect: Facial skin colour can vary for many reasons, but it may not be the best indicator of jaundice in individuals with dark skin.

Choice B reason

Shoulders is incorrect: The shoulders are not typically indicative of jaundice.

Choice C reason:

Palm of the hands is incorrect: While the palm of the hands can sometimes show yellowing in cases of jaundice, it is less reliable than observing the sclera.

Choice D reason:

Sclera is the best location. In individuals with darker skin tones, yellowish discoloration of the skin due to jaundice can be more challenging to detect. However, the sclera of the eyes can still show noticeable yellowing, making it a reliable location for assessing jaundice in individuals with both light and dark skin.

A. Strict adherence to routines B. Difficulty paying attention to tasks C. Disobedience to authority figures D. Excessive anxiety when separated from parents

Correct Answer is A

Explanation

A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.

B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attention-deficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.

C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.

D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a skin assessment on a client who has a dark skin. Which one of the following locations on the client’s body should the nurse observe to access for jaundice?

Correct Answer is D

Explanation

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

8-year-old male admitted with cystic fibrosis reports: Shortness of breath Wheezing throughout lung fields Productive cough with thick sputum A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?

A nurse is providing phone advice for a client who is pregnant. Complete the following sentence by using the lists of options. Exhibits The client is at risk for experiencing dropdown due to the dropdown.

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

A nurse is preparing to administer levothyroxine 50 micrograms to a client. Available is levothyroxine 0.025 mg/tablet. How many tablets should the nurse administer per dose? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?