A client has been diagnosed with hypothyroidism. What information should the nurse obtain when conducting a focused assessment? Select all that apply.

Weight gain

Constipation

Rapid pulse

Decreased energy

Hypertension

Answer and Explanation

Correct Answer : A,B,D

Choice A Reason: Weight gain is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the metabolism to slow down and the body to store more fat.

Choice B Reason: Constipation is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the gastrointestinal motility to decrease and the stools to become hard and dry.

Choice C Reason: Rapid pulse is not a common finding in hypothyroidism, but it may indicate other conditions such as hyperthyroidism or anxiety.

Choice D Reason: Decreased energy is a common finding in hypothyroidism, as the decreased thyroid hormone level causes the body to feel tired and sluggish.

Choice E Reason: Hypertension is not a common finding in hypothyroidism, but it may indicate other conditions such as renal disease or cardiovascular disease.

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Correct Answer is A

Explanation

Choice A Reason: Contacting the health care provider is the first nursing action that the nurse should perform, as it indicates that the client may have compartment syndrome, which is a medical emergency that requires immediate intervention to prevent tissue necrosis and nerve damage.

Choice B Reason: Administering PRN pain medication is not the first nursing action that the nurse should perform, as it may not relieve the pain and may mask the symptoms of compartment syndrome.

Choice C Reason: Documenting the findings is not the first nursing action that the nurse should perform, as it may delay the treatment and worsen the outcome of compartment syndrome.

Choice D Reason: Elevating the extremity is not the first nursing action that the nurse should perform, as it may decrease blood flow and increase tissue ischemia in compartment syndrome.

A. Irrigate the fistula with 3 mL of normal saline solution. B. Flush the fistula with 1 mL of heparin solution once per shift. C. Infuse 50 mL of normal saline once per 24 hours. D. Palpate for a vibrating sensation at the fistula site.

Correct Answer is D

Explanation

Choice A Reason: Irrigating the fistula with 3 mL of normal saline solution is not a correct way to assess the patency of the fistula, as it may cause bleeding, infection, or dislodgement of the fistula.

Choice B Reason: Flushing the fistula with 1 mL of heparin solution once per shift is not a correct way to assess the patency of the fistula, as it may cause clotting, infection, or allergic reaction.

Choice C Reason: Infusing 50 mL of normal saline once per 24 hours is not a correct way to assess the patency of the fistula, as it may cause fluid overload, hypertension, or edema.

Choice D Reason: Palpating for a vibrating sensation at the fistula site is a correct way to assess the patency of the fistula, as it indicates that there is adequate blood flow through the fistula. This sensation is also known as a thrill.

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A client has been diagnosed with hypothyroidism. What information should the nurse obtain when conducting a focused assessment? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

I can help you with formatting and editing the text. Here are the edited texts: Text 1: A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula?

Correct Answer is D

Explanation

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