A client who has a history of hypothyroidism was admitted with lethargy and confusion. Which additional finding warrants immediate action by the nurse?
Haematocrit of 30% (0.30 volume fraction).
Facial puffiness and periorbital enema.
Further decline in level of consciousness.
Cold and dry skin.
The Correct Answer is C
Choice A reason: A haematocrit of 30% is below the normal range and indicates anaemia, which is common in hypothyroidism. However, it does not require immediate intervention compared to a decline in consciousness.
Choice B reason: Facial puffiness and periorbital enema are common signs of hypothyroidism but do not require immediate intervention. They are more indicative of chronic, rather than acute, issues.
Choice C reason: A further decline in level of consciousness is critical and warrants immediate action. It can indicate a myxoedema coma, a severe complication of hypothyroidism that is life-threatening and requires urgent treatment.
Choice D reason: Cold and dry skin is a common symptom of hypothyroidism but does not require immediate intervention compared to a decline in consciousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Stool with fatty streaks is not a common finding in ulcerative colitis. It is more associated with malabsorption syndromes.
Choice B reason: Blood in the stool is a significant finding in ulcerative colitis, especially during an acute exacerbation. It indicates active inflammation and potential bleeding in the colon, which requires immediate attention and intervention.
Choice C reason: Clay-coloured stool usually indicates a problem with the bile ducts or liver, such as bile duct obstruction. It is not specific to ulcerative colitis.
Choice D reason: Hard pellets of stool indicate constipation, which is not typically associated with ulcerative colitis, especially during an acute exacerbation where diarrhea is more common.
Correct Answer is B
Explanation
Choice A reason: Amber urine is not unusual and can be related to dehydration. Although it should be monitored, it is not the most urgent finding in this scenario.
Choice B reason: Yellow sclera is a sign of jaundice, which occurs when there is a significant buildup of bilirubin in the blood. This is a critical indicator of a blocked bile duct and requires immediate medical attention to prevent severe complications.
Choice C reason: Flatulence is common with gastrointestinal disturbances but is not an urgent finding compared to jaundice.
Choice D reason: Belching is also common in digestive disorders and not as concerning as the presence of jaundice, which indicates a potentially serious problem with bile drainage.
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