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.

Answer and Explanation

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.

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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.

A. Administer IV furosemide. B. Insert an indwelling urinary catheter. C. Monitor for telemetry ST segment changes. D. Give a bronchodilator per inhaler.

Correct Answer is A

Explanation

Choice A reason: Administering IV furosemide (a diuretic) is crucial for managing the client's symptoms of fluid overload, as indicated by enema and elevated brain natriuretic peptide (BNP) levels. Furosemide helps reduce the volume of fluid in the body, relieving symptoms of heart failure and improving breathing. It addresses the most urgent need for the client.

Choice B reason: Inserting an indwelling urinary catheter might be necessary for accurate measurement of urine output, especially in a client receiving diuretic therapy. However, it is not the most immediate intervention needed to stabilize the client's condition.

Choice C reason: Monitoring for telemetry ST segment changes is important for clients with cardiac conditions. While it is necessary for ongoing assessment, it does not address the immediate need to relieve fluid overload and improve the client's respiratory status.

Choice D reason: Giving a bronchodilator per inhaler can help with respiratory symptoms related to emphysema. However, in this scenario, the primary issue is fluid overload due to heart failure, which needs to be addressed first with diuretic therapy.

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A client who has a history of hypothyroidism was admitted with lethargy and confusion. Which additional finding warrants immediate action by the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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