The nurse is admitting a client with a thyroid disorder who presents with periorbital edema, cold intolerance, and weight gain. Which intervention should the nurse include in this client's plan of care?

Administer propylthiouracil (PTU).

Provide an electric blanket.

Restrict fluids.

Monitor for hypotension.

Answer and Explanation

The Correct Answer is A

Choice A reason: Propylthiouracil (PTU) is an antithyroid medication used to treat hyperthyroidism, which can present with symptoms such as weight loss and heat intolerance. The symptoms listed (periorbital edema, cold intolerance, and weight gain) suggest hypothyroidism, for which PTU is not indicated.

Choice B reason: Providing an electric blanket may offer comfort for cold intolerance but does not address the underlying thyroid disorder.

Choice C reason: Restricting fluids is not a standard intervention for thyroid disorders and could potentially lead to dehydration.

Choice D reason: Monitoring for hypotension is important in thyroid disorders, especially if the client is on antithyroid medications, which can affect blood pressure. However, the symptoms presented suggest hypothyroidism, where hypotension is less of a concern compared to hyperthyroidism.

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Correct Answer is A

Explanation

Choice A reason: The serum lactate level of 3.9 mmol/L is significantly higher than the normal range of 0.5-2 mmol/L. This is a critical value to report as it indicates a high likelihood of sepsis, which is a life-threatening condition requiring immediate intervention. Elevated lactate levels suggest that the tissues are not adequately oxygenated, a state known as tissue hypoxia, which is a hallmark of sepsis.

Choice B reason: While the vital signs show a slight fever (100°F), the heart rate, respiratory rate, and blood pressure are within normal limits for an adult and do not indicate an immediate life-threatening condition.

Choice C reason: A pulse oximetry reading of 96% on supplemental oxygen is within the acceptable range, indicating adequate oxygen saturation and not a direct sign of sepsis.

Choice D reason: The presence of rhonchi bilaterally suggests airway obstruction due to mucus, which can be associated with pneumonia. However, this finding alone does not carry the same immediate risk of morbidity and mortality as an elevated lactate level indicative of sepsis.

A. Slowed movement when rising from a chair B. Chronic diarrhea C. Difficulty swallowing D. Shuffling gait

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Slowed movement when rising from a chair is a common symptom of Parkinson's disease, known as bradykinesia.

Choice B reason: Chronic diarrhea is not typically associated with Parkinson's disease.

Choice C reason: Difficulty swallowing, or dysphagia, is a common issue in Parkinson's disease due to impaired muscle control.

Choice D reason: A shuffling gait is characteristic of Parkinson's disease, often referred to as "festinating gait."

Choice E reason: Lower extremity edema is not a typical symptom of Parkinson's disease and may indicate other health issues.

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The nurse is admitting a client with a thyroid disorder who presents with periorbital edema, cold intolerance, and weight gain. Which intervention should the nurse include in this client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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