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

Explanation

A) Correct- With a significantly low platelet count, the risk of bleeding is elevated. Assessing urine and stool for occult (hidden) blood is important to detect any signs of internal bleeding that may not be immediately apparent. A low platelet count increases the risk of spontaneous bleeding, which can be life-threatening if undetected.
B) Incorrect- This choice is related to neutropenia, not thrombocytopenia. Neutropenia, or low neutrophil count, increases the risk of infection, which is why monitoring temperature frequently is important.

C) Incorrect- Monitoring for signs of activity intolerance is not directly related to the low platelet count. The primary concern with thrombocytopenia is the risk of bleeding, not generalized activity intolerance.
D) Incorrect- Requiring visitors to wear respiratory masks is not relevant to the client's current condition of low platelet count. This action is related to infection control and protection from respiratory infections.

A. Have the client demonstrate technique used to monitor blood glucose levels. B. Evaluate the client's asthma medications that can elevate the blood glucose. C. Ask the client if they want a different manufacturer's glucose monitoring device. D. Have the client describe a typical day at work, home, and social activities. E. Determine if the client is using a new insulin needle each administration.

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

Explanation

A) Correct - Demonstrating the technique used to monitor blood glucose levels is crucial.

Incorrect technique can lead to inaccurate readings, impacting insulin dosing decisions and blood sugar control.
B) Correct - Some asthma medications, like corticosteroids, can elevate blood glucose levels.

Evaluating the client's asthma medications is essential as they can contribute to fluctuations in blood sugar levels.
C) Incorrect- Asking the client if they want a different manufacturer's glucose monitoring device is not helpful, because it does not address the underlying causes of the poor glycemic control. The client may also perceive this as a lack of confidence in their ability to manage their diabetes or as a criticism of their choice of device. The nurse should focus on educating the client on how to use their current device correctly and consistently, rather than suggesting a change that may not be necessary or feasible.
D) Correct - Understanding the client's daily routine helps identify factors influencing blood glucose control, such as meal timing, activity level, and stress. This information aids in creating a personalized diabetes management plan.
E) Correct - Ensuring the client uses a new insulin needle for each administration is important for preventing infection and complications. Reusing needles can affect injection site health and insulin absorption.

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Naxlex Comprehensive Predictor Exams

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]

Correct Answer is A

Explanation

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

Explanation

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