A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?
Anxiety
Hyperglycemia
Fever
Dyspnea.
The Correct Answer is D
A. Anxiety is a common symptom in patients with thyrotoxicosis due to increased metabolic activity and overstimulation of the nervous system. While anxiety can be distressing, it is not typically life- threatening and does not usually require immediate intervention.
B. Hyperglycemia (high blood glucose levels) can occur in patients with thyrotoxicosis due to increased metabolic rate and potential effects on insulin sensitivity. It requires monitoring and management but typically does not demand immediate intervention unless it is severe and causing other complications.
C. Fever can be a sign of thyroid storm, a severe form of thyrotoxicosis that can be life-threatening. Elevated body temperature in the context of thyrotoxicosis requires prompt assessment as it may indicate an underlying severe condition or complications.
D. Dyspnea is a critical symptom that warrants immediate intervention. In the context of thyrotoxicosis, it may indicate a severe complication such as heart failure, thyroid storm, or respiratory distress. Given that dyspnea can lead to compromised oxygenation and potentially life-threatening situations, it is the most urgent symptom to address.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While excessive consumption of certain beverages can potentially affect urinary health, diet drinks are generally not a primary risk factor for UTIs. The key risk factors for UTIs typically involve issues related to urinary retention, hygiene, and anatomical predispositions rather than beverage consumption alone.
B. Not voiding when the urge occurs, also known as urinary retention, can increase the risk of UTIs. When urine is retained in the bladder for extended periods, it can provide an environment where bacteria can proliferate, leading to infections. This behavior is a significant risk factor for developing UTIs, as it contributes to urinary stasis.
C. A multipara with a history of pyelonephritis is at increased risk for future UTIs. A history of pyelonephritis indicates that the client has experienced a serious urinary infection in the past, which could make her more susceptible to recurrent infections. This is a significant risk factor for developing UTIs again.
D. Urinary incontinence, especially in older adults, can be associated with increased risk for UTIs due to factors like poor hygiene, the presence of residual urine, and possible skin breakdown. While incontinence is a risk factor, it is often considered less directly related to recurrent UTIs compared to issues like urinary retention or a history of severe infections.
Correct Answer is B
Explanation
A. Weight gain is a common symptom of hypothyroidism but it is not an immediate threat to life. It can be managed with diet and medication.
B. Hypoventilation, or decreased respiratory rate, can lead to hypoxemia (low oxygen levels in the blood) and hypercapnia (increased carbon dioxide levels in the blood). These conditions can rapidly deteriorate into a respiratory crisis and require immediate intervention.
C. Cold intolerance is a common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with warm clothing and a warm environment.
D. Lethargy is another common symptom of hypothyroidism but is not an immediate threat to life. It can be managed with medication and lifestyle changes.
8. The nurse reviews discharge instructions with a client
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