A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement?
Offer additional blankets and a warm drink.
Note the client's most recent hemoglobin level.
Administer prescribed dose of levothyroxine.
Assess for presence of non-pitting edema.
The Correct Answer is C
A) Incorrect- While providing comfort measures like blankets and warm drinks can help the client feel more comfortable, they do not address the underlying thyroid hormone imbalance.
B) Incorrect- Hemoglobin level is not directly related to the client's symptoms or the thyroid hormone imbalance. Monitoring hemoglobin is important in assessing anemia but is not the priority in this case.
C) Correct- The client's symptoms (raspy voice, cold intolerance, fatigue) along with an elevated TSH and low T3 and T4 levels suggest hypothyroidism. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. Administering the prescribed dose of levothyroxine is crucial to address the thyroid hormone imbalance and alleviate the symptoms.
D. Incorrect- Non-pitting edema is not a common symptom of hypothyroidism. The client's symptoms and lab results are more indicative of hypothyroidism, and addressing the thyroid hormone imbalance is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.
Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.
The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.
While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.
Correct Answer is B
Explanation
A) Incorrect- Genetically inherited disorders of family members: While a family history of certain disorders might provide some insight, it is not typically the primary cause of elevated serum magnesium levels in an older adult.
B) Correct- Elevated serum magnesium levels are commonly associated with chronic laxative use, especially those containing magnesium-based compounds. Laxatives can lead to excessive magnesium intake, causing hypermagnesemia.
C. Incorrect- Smoking is not a common cause of elevated serum magnesium levels.
D. Incorrect- While dietary sources can contribute to magnesium intake, chronic laxative use is a more likely cause in this context.
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