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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Acute kidney injury (AKI) can have significant impacts on the client's fluid and electrolyte balance. Mannitol, a diuretic, is commonly used to promote diuresis and increase urine
output in cases of AKI. However, it is essential to assess the client's hemodynamic status and overall condition before administering mannitol.
Obtaining vital signs (such as blood pressure, heart rate, respiratory rate, and temperature) helps evaluate the client's baseline status and monitor for any changes that may occur after administering mannitol. It is particularly important to assess blood pressure as mannitol can potentially cause hypotension as a side effect.
Assessing breath sounds is also crucial because pulmonary edema can occur as a complication of AKI. Mannitol administration may exacerbate this condition. Therefore, assessing breath sounds allows the nurse to monitor for signs of fluid overload, such as crackles or wheezes.
Collecting a clean catch urine specimen may be necessary for diagnostic purposes to assess kidney function and determine the presence or severity of acute kidney injury. However, obtaining vital signs and assessing breath sounds should be the first nursing intervention before administering any medication, including mannitol, to ensure the client's safety and monitor for any potential adverse effects.
Correct Answer is C
Explanation
Delegation involves assigning tasks to individuals who have the appropriate skills and competence to perform them safely and effectively. Inserting urinary catheters for uncomplicated clients is a task that can be delegated to a practical nurse. It is a common procedure within the scope of practice for a practical nurse, and it does not require the level of assessment and critical thinking involved in evaluating and updating plans of care or receiving a postoperative client and conducting an assessment.
Verifying the readiness of clients for discharge typically involves comprehensive assessments, coordination with other healthcare professionals, and decision-making regarding the appropriateness of discharge. This task is generally performed by registered nurses (RNs) or other members of the healthcare team with advanced training.
Evaluating and updating plans of care for clients is a responsibility that falls within the scope of practice of registered nurses. It requires a higher level of assessment, clinical judgment, and decision-making, which are typically beyond the scope of practice of a practical nurse.
Receiving a postoperative client and conducting the assessment involves comprehensive assessment skills and critical thinking, which are typically within the scope of practice of a registered nurse or an advanced practice nurse.
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