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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["1.4"]

Explanation

Calculate the total dosage required: 44 mcg/kg * 65 kg = 2860 mcg. Convert mcg to mg: 2860 mcg ÷ 1000 = 2.86 mg.

Divide by concentration: 2.86 mg ÷ 2 mg/mL = 1.43 mL.

Considering the vial contains 2 mg/mL, the nurse should administer around 1.43 mL, which can be rounded to 1.4 mL.

A. The amount of time the child was submerged B. Temperature of water C. Whether or not anyone witnessed the fall into the pool D. Oxygen concentration of the ambient air E. The weight of the child

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

Explanation

A) Correct- The duration of submersion is a critical factor in determining the potential level of hypoxemia. Prolonged submersion leads to a higher risk of severe hypoxia and its associated complications.
B) Incorrect- While water temperature can affect the body's response to submersion, it is not directly related to the level of hypoxemia. Hypoxemia primarily results from the lack of oxygen intake during submersion.
C) Correct- Witnessing the fall into the pool is important because immediate initiation of cardiopulmonary resuscitation (CPR) can improve the chances of a positive outcome. Bystander CPR can help maintain oxygenation and circulation until professional help arrives.
D) Correct- The oxygen concentration in the surrounding air is crucial for oxygen delivery to the body's tissues. In cases of submersion, the availability of oxygen in the air the child is breathing plays a role in determining the level of hypoxemia.
E) Incorrect- The weight of the child is not a significant factor in determining the level of hypoxemia during submersion. The primary determinants are factors like submersion duration, availability of oxygen, and prompt initiation of CPR.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.4"]

Explanation

Exhibits here Review H and P. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

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

Explanation

Exhibits The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history. What should the nurse advise the parents concerning the child's nutrition? Select all that apply

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