The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

Evaluate pupil reactions every shift

Assess temperature every 4 hours

Monitor for cyanosis

Check reflexes

Answer and Explanation

The Correct Answer is C

Choice A reason: Evaluating pupil reactions every shift is important for neurological assessment but is not directly related to monitoring tissue perfusion.

Choice B reason: Assessing temperature every 4 hours is a standard monitoring procedure for sepsis but does not specifically address tissue perfusion.

Choice C reason: Monitoring for cyanosis is a direct method to assess tissue perfusion. Cyanosis, a bluish discoloration of the skin, indicates poor oxygenation and is a sign of decreased tissue perfusion.

Choice D reason: Checking reflexes is part of a neurological assessment and, while important, it does not directly monitor tissue perfusion.

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Correct Answer is C

Explanation

Choice A reason: Less constipation is not a direct indicator of effective PTU therapy, as constipation can be associated with hypothyroidism, and PTU is used to treat hyperthyroidism.

Choice B reason: Weight loss is expected in hyperthyroidism, and PTU is used to reduce thyroid hormone levels, not to promote weight loss.

Choice C reason: A reduction in facial puffiness can indicate that the PTU is effectively reducing thyroid hormone levels, as puffiness can be associated with hyperthyroidism.

Choice D reason: Improvement in vision is not a typical outcome of PTU therapy and does not directly indicate its effectiveness.

A. "I always need to have a sweater or jacket on." B. "I am always warm and sometimes even hot during cold weather." C. "I seem to have episodes of hot and cold without regard to what I am wearing." D. "My fingers are sometimes cold during the cooler weather."

Correct Answer is B

Explanation

Choice A reason: Needing a sweater or jacket is not typical for Graves' disease, which often causes intolerance to heat rather than cold.

Choice B reason: This response is typical for Graves' disease, as hyperthyroidism can increase metabolism, leading to feeling warm or hot even in cold weather.

Choice C reason: While temperature dysregulation can occur, the specific symptom of feeling warm in cold weather is more directly associated with Graves' disease.

Choice D reason: Cold fingers can be a symptom of many conditions, but it is not specifically indicative of Graves' disease.

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The nurse is caring for a client with sepsis. Which intervention would the nurse include to monitor for decreased tissue perfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with thyroid disease is being treated with propylthiouracil (PTU). Which statement made by the client indicates the medication therapy is effective?

Correct Answer is C

Explanation

The nurse is interviewing a client with possible Graves' disease. Which response would the nurse expect when asking the client about her comfort in cold weather?

Correct Answer is B

Explanation

Which client does the nurse identify as having the greatest risk for the development of sepsis?

The nurse is caring for a client with chronic pancreatitis. Which intervention is appropriate for this diagnosis?

The nurse is assessing a client diagnosed with Parkinson's disease. Which data would the nurse anticipate? Select all that apply.

The nurse is providing education to the client with Parkinson's disease and their family. The nurse understands that teaching has not been effective when the client makes which of the following statements?

The nurse is reviewing data of a client receiving propylthiouracil (PTU). Which information indicates to the nurse that the client may be experiencing a side effect of this medication?

The nurse suspects the client's dose of levothyroxine (Synthroid) is too low when the client displays which symptom?