The nurse is assessing a patient with a history of Graves' disease. The assessment is in the chart below. Which interventions will the nurse include in the plan of care? (Select All That Apply)

Assessment:

Respiratory Rate: 28 breaths/minute

Heart rate: 145 beats/minute and irregular

Temperature: 102.2°F (39°C)

Blood pressure: 167/80 mmHg

Level of consciousness: Decreased

Apply a hypothermia blanket.

Administer humidified oxygen.

Administer aspirin 325 mg orally.

Administer D5NS intravenous infusion.

Administer propylthiouracil.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Applying a hypothermia blanket is appropriate for managing hyperthermia in a patient with Graves' disease. Elevated temperatures (fever) are common in thyroid storm, a severe complication of Graves' disease. Using a hypothermia blanket helps reduce the body temperature and prevent further complications.

Choice B reason: Administering humidified oxygen is important for supporting respiratory function in a patient with increased respiratory rate and decreased level of consciousness. Humidified oxygen can help alleviate respiratory distress and improve oxygenation.

Choice C reason: Administering aspirin 325 mg orally is not recommended for patients with hyperthyroidism or thyroid storm. Aspirin can increase free thyroid hormone levels by displacing thyroid hormone from its binding proteins, potentially worsening the patient's condition. Acetaminophen is a safer alternative for managing fever in these patients.

Choice D reason: Administering D5NS intravenous infusion is appropriate for managing dehydration and electrolyte imbalances in a patient with thyroid storm. This intervention helps maintain fluid balance and provides dextrose for energy.

Choice E reason: Administering propylthiouracil is a key intervention for managing thyroid storm. Propylthiouracil inhibits thyroid hormone synthesis and peripheral conversion of T4 to T3, helping to reduce thyroid hormone levels and alleviate symptoms.

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Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Kussmaul breathing is a deep, labored breathing pattern that is a compensatory mechanism for metabolic acidosis, commonly seen in diabetic ketoacidosis.

Choice B reason: Abdominal pain is a common symptom in diabetic ketoacidosis due to the metabolic disturbances and dehydration.

Choice C reason: A positive Trousseau sign is associated with hypocalcemia and is not a common manifestation of diabetic ketoacidosis.

Choice D reason: Decreased heart rate is not typical in diabetic ketoacidosis. In fact, patients might present with an increased heart rate due to dehydration and acidosis.

Choice E reason: Confusion is a symptom of diabetic ketoacidosis due to the effects of severe hyperglycemia and metabolic acidosis on the brain.

A. Bronchoconstriction B. Pulmonary edema C. Hemoptysis D. Pneumothorax

Correct Answer is A

Explanation

Choice A reason: Wheezing is a typical sound heard during bronchoconstriction, which occurs in conditions like asthma and COPD. It indicates that the airways are narrowed, causing the characteristic sound.

Choice B reason: Pulmonary edema typically presents with crackles or rales rather than wheezing. Wheezing would not be the primary indication of this condition.

Choice C reason: Hemoptysis refers to coughing up blood and does not typically present with wheezing. It might present with other sounds if there is an underlying lung issue, but wheezing is not specific to it.

Choice D reason: Pneumothorax generally presents with decreased or absent breath sounds on one side, not wheezing. It occurs when air enters the pleural space, causing lung collapse.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with diabetic ketoacidosis (DKA). What clinical manifestations will the nurse anticipate the patient to present? (Select All That Apply)

Correct Answer is ["A","B","E"]

Explanation

The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) who is reporting dyspnea. The nurse auscultates the patient's chest and hears wheezing throughout the lung fields. What does this finding indicate to the nurse about this patient?

Correct Answer is A

Explanation

The nursing student is reviewing the chart of a patient admitted with ulcerative colitis. Which findings will the student identify to the nursing instructor as consistent with the patient's diagnosis? (Select All That Apply)

The nurse is caring for a patient diagnosed with small bowel obstruction. A nasogastric tube with low continuous suction has been in place for 72 hours. Upon reviewing the blood work, which lab results will the nurse expect to see?

The nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which lab results will the nurse expect to find to support this diagnosis?

The nurse is caring for a patient with metabolic alkalosis. What will the nurse recognize as the common cause of this acid-base imbalance?

The nurse is teaching a patient with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. The patient demonstrates understanding of hypoglycemia by stating they will check their blood glucose when experiencing which of the following symptoms?

The nurse is in the G unit is assessing a patient after receiving the change of shift SBAR report. What assessment findings will the nurse report immediately to the provider?

The nurse is caring for a patient after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding will the nurse report to the health care provider?