A client whose hyperthyroidism has not been responsive to medications is admitted for evaluation. During the admission assessment the client reports to the nurse of a sudden onset of feeling apprehensive and nurse notes the client is restless and very warm to touch. Which action should the nurse implement next?

Access laboratory results to confirm a thyroid crisis.

Obtain a complete set of vital signs.

Initiate intravenous access.

Encourage relaxation and slow deep breathing.

Answer and Explanation

The Correct Answer is C

In this scenario, the client's sudden onset of feeling apprehensive, restlessness, and increased body temperature are consistent with symptoms of a thyroid crisis, also known as thyroid storm or thyrotoxic crisis. Thyroid crisis is a life-threatening condition that requires immediate medical intervention.

Initiating IV access is crucial to ensure the prompt administration of medications and fluids to manage the thyroid crisis effectively. IV access allows for the administration of beta-blockers, antithyroid drugs, and supportive care, which are essential components of the treatment for thyroid crisis. IV access also provides a route for fluid resuscitation if necessary.

Accessing laboratory results to confirm a thyroid crisis is important, but the clinical presentation of the client with sudden onset symptoms and a known history of uncontrolled hyperthyroidism suggests the need for immediate intervention rather than waiting for laboratory confirmation.

Obtaining a complete set of vital signs is an important assessment to gather comprehensive data, but in the case of a suspected thyroid crisis, immediate intervention takes precedence over obtaining vital signs.

Encouraging relaxation and slow deep breathing may be beneficial in managing anxiety or discomfort, but it does not address the underlying emergency situation of a thyroid crisis. The nurse should focus on initiating appropriate medical interventions first.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Fever increases fluid loss through perspiration.

Increased respiratory rate can lead to increased fluid loss through evaporation. Increased nasal secretions can result in fluid loss.

High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.

The following findings do not necessarily indicate increased fluid requirements: Blood pressure alone does not indicate increased fluid requirements.

Oxygen saturation within the normal range does not indicate increased fluid requirements.

Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.

Heart rate alone does not indicate increased fluid requirements.

A. A salad with three kinds of lettuce and fruit. B. Vegetable soup, crackers, and milk. C. A peanut butter sandwich with soda and cookies. D. A tuna fish sandwich with chips and ice cream.

Correct Answer is D

Explanation

A) Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.

D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D","E"]

Explanation

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

Correct Answer is D

Explanation

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching?

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?

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?