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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Regular exercise is a vital component of managing type 2 diabetes. It helps to lower blood glucose levels, improve insulin sensitivity, and increase HDL (the "good" cholesterol) levels. However, it is important for the client to obtain medical approval before starting or modifying an exercise regimen. The healthcare provider can assess the client's overall health status and provide specific recommendations regarding the type, duration, and intensity of exercise suitable for the client's individual needs and any potential limitations.

Limiting calories on days unable to exercise is a valid strategy for managing weight and blood glucose levels; however, it is not specifically related to increasing HDL levels. It is important to maintain a balanced and healthy diet overall.

Monitoring blood glucose levels daily is an important self-care practice for individuals with diabetes, but it is not specifically focused on increasing HDL levels. Blood glucose monitoring helps to assess the effectiveness of diabetes management and make necessary adjustments to medication, diet, or exercise.

Monthly appointments with the dietitian can be beneficial for diabetes management, as dietary modifications play a significant role. However, the instruction regarding exercise is more directly related to increasing HDL levels, and the frequency of appointments with the dietitian may vary based on individual needs and goals.

A. Refer the parents to the chaplain to provide grief counseling. B. Tell the parents that blaming each other will not change the situation C. Assure the parents that a terminal diagnosis is inevitable. D. Explain to the parents that anger is a common response to grief.

Correct Answer is D

Explanation

The correct answer is choice d. Explain to the parents that anger is a common response to grief.

Choice A rationale:

Referring the parents to the chaplain for grief counseling can be beneficial, but it may not address the immediate emotional outburst and the need for understanding their feelings.

Choice B rationale:

Telling the parents that blaming each other will not change the situation might be true, but it can come across as dismissive and may not provide the emotional support they need at that moment.

Choice C rationale:

Assuring the parents that a terminal diagnosis is inevitable does not address their current emotional state and may seem insensitive to their grief and anger.

Choice D rationale:

Explaining to the parents that anger is a common response to grief helps them understand their emotions and provides immediate emotional support, making it the best intervention in this situation.

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Naxlex Comprehensive Predictor Exams

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

Correct Answer is C

Explanation

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?

Correct Answer is D

Explanation

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement?

An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.)

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?