The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?

Pace the client's care to provide periods of rest.

Make arrangements for radioactive iodine therapy.

Administer beta-adrenergic blocking agent.

Monitor the client's vital signs frequently.

Answer and Explanation

The Correct Answer is D

Choice A reason: Pacing the client's care to provide periods of rest is important for managing fatigue and preventing overexertion. However, it is not the first action the nurse should take in this situation. Monitoring vital signs is crucial to assess the client's current condition and detect any immediate complications.

Choice B reason: Making arrangements for radioactive iodine therapy is a treatment option for hyperthyroidism. However, this is not the first action the nurse should take. The nurse needs to assess the client's condition and stabilize any immediate issues before considering long-term treatment options.

Choice C reason: Administering a beta-adrenergic blocking agent can help manage symptoms such as a racing heartbeat and nervousness. While this may be part of the treatment plan, it is not the first action the nurse should take. Monitoring vital signs is essential to determine the appropriate interventions.

Choice D reason: Monitoring the client's vital signs frequently is the first action the nurse should take. This helps assess the client's current condition, detect any immediate complications, and guide further interventions. It is crucial to ensure the client's stability before implementing other care measures.

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Correct Answer is B

Explanation

Choice A reason: Stool with fatty streaks is not a common finding in ulcerative colitis. It is more associated with malabsorption syndromes.

Choice B reason: Blood in the stool is a significant finding in ulcerative colitis, especially during an acute exacerbation. It indicates active inflammation and potential bleeding in the colon, which requires immediate attention and intervention.

Choice C reason: Clay-coloured stool usually indicates a problem with the bile ducts or liver, such as bile duct obstruction. It is not specific to ulcerative colitis.

Choice D reason: Hard pellets of stool indicate constipation, which is not typically associated with ulcerative colitis, especially during an acute exacerbation where diarrhea is more common.

A. Draw air in through the nose and exhale slowly through pursed lips. B. Increase breathing rate for a full 30 seconds. C. Raise hands above the head to expand the diaphragm. D. Lay down on each side with knees bent and breathe from the abdomen.

Correct Answer is A

Explanation

Choice A reason: Drawing air in through the nose and exhaling slowly through pursed lips is a technique known as pursed-lip breathing. This method helps improve gas exchange by keeping the airways open longer during exhalation, which aids in the removal of trapped air and reduces dyspneal.

Choice B reason: Increasing the breathing rate for a full 30 seconds is not recommended for clients with emphysema. Rapid breathing can lead to hyperventilation and increased work of breathing, which can exacerbate dyspneal.

Choice C reason: Raising hands above the head to expand the diaphragm might help in some situations, but it is not as effective as pursed-lip breathing for improving gas exchange and reducing dyspneal in clients with emphysema.

Choice D reason: Laying down on each side with knees bent and breathing from the abdomen is a relaxation technique that can help some clients, but it does not specifically address the need for improved gas exchange during episodes of dyspneal.

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The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements?

Correct Answer is B

Explanation

The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Correct Answer is A

Explanation

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