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: Alopecia, or hair loss, is a common symptom of systemic lupus erythematosus but does not require immediate follow-up. It is not life-threatening and can be managed as part of the overall treatment plan.

Choice B reason: Haematuria, or blood in the urine, requires immediate follow-up because it can indicate serious renal involvement or a possible flare-up of lupus nephritis. Kidney complications in lupus can lead to severe outcomes if not addressed promptly.

Choice C reason: Fatigue is a common symptom of lupus and while it can significantly impact the client's quality of life, it does not usually require urgent intervention. It is managed through ongoing treatment and lifestyle adjustments.

Choice D reason: Joint pain is another common symptom of lupus. Although it can be debilitating, it is not an emergency and can be managed through standard treatments for lupus.

A. Take a walk with the client. B. Sit the client in a recliner. C. Administer a sleeping medication. D. Move the client to a locked unit.

Correct Answer is A

Explanation

Choice A reason: Taking a walk with the client is an effective intervention for addressing agitation and restlessness in a client with Alzheimer's disease. Physical activity can help reduce anxiety and agitation, and walking provides a safe and structured way for the client to expend energy while being closely supervised.

Choice B reason: Sitting the client in a recliner may provide temporary comfort, but it does not address the underlying agitation and restlessness. The client may still attempt to leave the room and become more frustrated if their movement is restricted.

Choice C reason: Administering a sleeping medication can have sedative effects, but it should not be the first-line intervention for agitation and restlessness in clients with Alzheimer's disease. Non-pharmacological approaches, such as walking, should be tried first. Sedatives can also increase the risk of falls and other complications.

Choice D reason: Moving the client to a locked unit may be necessary for safety in some cases, but it should not be the initial intervention for agitation and restlessness. The goal is to use less restrictive interventions first to manage the client's behaviour.

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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

The nurse completes the admission assessment of a client with systemic lupus erythematosus. Which finding requires immediate follow-up by the nurse?

Correct Answer is B

Explanation

During the evening shift, a client with Alzheimer's disease becomes agitated, restless, and repeatedly attempts to leave the room unattended. Which intervention should the nurse implement?

Correct Answer is A

Explanation

A male client comes to the clinic with concerns of erectile dysfunction (ED). Which information is most important for the nurse to obtain?

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