A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?
Facial puffiness and periorbital edema.
Cold and dry skin.
Further decline in level of consciousness.
Hematocrit of 30% (0.30).
The Correct Answer is C
A. Facial puffiness and periorbital edema:
These are common signs of hypothyroidism but may not require immediate action unless accompanied by severe symptoms.
B. Cold and dry skin:
Cold and dry skin is a characteristic feature of hypothyroidism, but a further decline in the level of consciousness is a more urgent issue.
C. Further decline in the level of consciousness.
A decline in the level of consciousness is a critical sign that requires immediate attention, as it may indicate worsening hypothyroidism, myxedema coma, or other serious complications. Myxedema coma is a life-threatening condition associated with severe hypothyroidism, and it requires prompt medical intervention.
D. Hematocrit of 30% (0.30):
While anemia is a potential complication of hypothyroidism, a hematocrit of 30% alone may not be the most immediate concern compared to a decline in the level of consciousness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Carefully cleans and peels all fresh fruit and vegetables:
While cleaning and peeling fresh fruits and vegetables may contribute to food safety, it is not a specific indication of adherence to the DASH eating plan.
B. Uses only lactose-free dairy products:
The DASH eating plan encourages the consumption of low-fat or fat-free dairy products. Using lactose-free dairy products may be necessary for individuals with lactose intolerance, but it is not a specific behavior related to the DASH plan.
C. No longer includes grains in the daily diet:
The DASH eating plan includes whole grains as part of a balanced diet. Eliminating grains altogether is not consistent with the DASH plan, which encourages the consumption of whole grains.
D. Enjoys fat-free yogurt as an occasional snack food:
This is the correct answer. The DASH eating plan recommends the inclusion of low-fat or fat-free dairy products as part of a heart-healthy diet. Choosing fat-free yogurt as an occasional snack aligns with the principles of the DASH plan, which emphasizes low-fat dairy options.
Correct Answer is B
Explanation
A. Administer intravenous fluid bolus as prescribed by the healthcare provider.
While hydration is important, the vital signs provided (elevated heart rate and respiratory rate) are more indicative of potential respiratory distress. Administering fluids may be indicated in certain situations, but it may not address the immediate concern of compromised oxygenation.
B. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter.
This is the correct choice. The client's elevated heart rate and respiratory rate suggest the need for improved oxygenation. Applying oxygen at a high flow rate via a non-rebreather mask is an immediate intervention to address potential respiratory compromise. Monitoring the pulse oximeter provides real-time feedback on oxygen saturation.
C. Medicate for pain and monitor vital signs according to protocol.
Pain management is an important aspect of post-operative care, but the immediate concern in this scenario is the potential for respiratory distress. Administering pain medication alone may not address the primary issue.
D. Encourage the client to splint the incision with a pillow to cough and deep breathe.
While encouraging the client to cough and deep breathe is important for post-thoracotomy care, the elevated vital signs suggest a need for more immediate intervention to ensure adequate oxygenation. Applying oxygen and monitoring the pulse oximeter take precedence.
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