A nurse is caring for a client who reports increased anxiety, nervousness, heat intolerance, and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH), elevated thyroxine (T4), and elevated triiodothyronine (T3). Which of the following vital sign abnormalities does the nurse anticipate?
Decreased body temperature
Tachycardia
Hypotension
Slow respiratory rate
The Correct Answer is B
Choice A reason: Decreased Body Temperature
Decreased body temperature is not typically associated with hyperthyroidism. In fact, hyperthyroidism often causes an increase in body temperature due to the accelerated metabolic rate. Patients with hyperthyroidism may experience heat intolerance and excessive sweating, but not a decrease in body temperature.
Choice B reason: Tachycardia
Tachycardia, or an abnormally fast heart rate, is a common symptom of hyperthyroidism. The elevated levels of thyroid hormones (T4 and T3) increase the body’s metabolism, leading to an increased heart rate. This can result in palpitations and a feeling of a racing heart, which are characteristic signs of hyperthyroidism. Therefore, tachycardia is the most likely vital sign abnormality in this scenario.
Choice C reason: Hypotension
Hypotension, or low blood pressure, is not typically associated with hyperthyroidism. Instead, hyperthyroidism can sometimes cause an increase in blood pressure due to the heightened metabolic activity and increased cardiac output4. Therefore, hypotension is not a characteristic finding in patients with elevated thyroid hormone levels.
Choice D reason: Slow Respiratory Rate
A slow respiratory rate is not commonly seen in hyperthyroidism. The condition usually leads to an increased respiratory rate due to the body’s heightened metabolic demands. Patients with hyperthyroidism may experience shortness of breath and rapid breathing, but not a slow respiratory rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Serum phosphate levels are not the primary concern in the management of diabetes insipidus (DI). While phosphate levels are important for overall health, they do not directly relate to the condition or its treatment with desmopressin. DI primarily affects water balance and sodium levels in the body.
Choice B reason:
Serum calcium levels, although important, are not the most critical lab value to monitor in a client with DI receiving desmopressin. Calcium levels are crucial for bone health and various metabolic functions, but they do not directly reflect the effectiveness or complications of desmopressin therapy.
Choice C reason:
Serum sodium levels are the most important lab value to monitor in a client with DI receiving desmopressin. DI causes an imbalance in water regulation, leading to excessive urination and potential dehydration. Desmopressin helps to reduce urine output and maintain water balance, but it can also lead to water retention and hyponatremia (low sodium levels). Monitoring serum sodium is crucial to prevent complications such as seizures, confusion, and other neurological symptoms associated with hyponatremia.
Choice D reason:
Blood urea nitrogen (BUN) levels are useful in assessing kidney function and hydration status, but they are not the primary concern in the management of DI with desmopressin. While BUN levels can provide valuable information about renal function, they do not directly indicate the effectiveness or potential complications of desmopressin therapy.
Correct Answer is D
Explanation
Choice A reason: Hypokalemia
Hypokalemia refers to a low level of potassium in the blood. It can cause muscle weakness, cramps, and arrhythmias, but it is not directly related to Kussmaul breathing. Hypokalemia can occur in diabetic ketoacidosis (DKA) due to the loss of potassium in urine, but it is not the primary cause of Kussmaul breathing. Kussmaul breathing is a deep, labored breathing pattern that occurs as a compensatory mechanism for metabolic acidosis, not directly due to low potassium levels.
Choice B reason: Metabolic Alkalosis
Metabolic alkalosis is a condition characterized by an elevated pH in body tissues due to an excess of bicarbonate or a loss of acid. It is the opposite of metabolic acidosis. Kussmaul breathing is specifically a response to metabolic acidosis, not alkalosis. Therefore, metabolic alkalosis is not related to Kussmaul breathing.
Choice C reason: Lipolysis
Lipolysis is the metabolic process of breaking down lipids (fats) into free fatty acids and glycerol. This process is accelerated in diabetic ketoacidosis (DKA) due to the lack of insulin, leading to the production of ketone bodies, which contribute to metabolic acidosis. While lipolysis is a part of the pathophysiology of DKA, it is not directly related to Kussmaul breathing. Kussmaul breathing is a compensatory mechanism for the acidosis caused by the accumulation of ketone bodies.
Choice D reason: Hyperglycemia
Hyperglycemia, or high blood sugar, is a hallmark of diabetic ketoacidosis (DKA). In DKA, the lack of insulin leads to elevated blood glucose levels and the breakdown of fats into ketones, causing metabolic acidosis. Kussmaul breathing is the body’s attempt to compensate for this acidosis by increasing the rate and depth of breathing to expel more carbon dioxide, thereby reducing the acidity of the blood. Therefore, hyperglycemia is directly related to the occurrence of Kussmaul breathing in DKA.
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