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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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

Explanation

The correct answer/s is Choice/s A, C, and E.

Choice A rationale: Obtaining the client’s tympanic temperature measurement is a crucial step. The client’s confusion and disorientation could be symptoms of an infection, such as a urinary tract infection or pneumonia. Infections in older adults can often present with atypical symptoms, including changes in mental status. Therefore, checking the client’s temperature can help identify if the client has a fever, which is a common sign of an infection.

Choice B rationale: While it’s always important to be aware of a client’s allergies, especially when administering medications, it doesn’t directly address the immediate concern of the client’s altered mental status. Therefore, it’s not the most appropriate action to take in response to the situation described.

Choice C rationale: Asking if the client is experiencing any pain with urination is relevant because urinary tract infections (UTIs) are common in older adults and can cause confusion and other changes in mental status. Pain during urination is a common symptom of a UTI.

Choice D rationale: Encouraging the intake of high protein foods is generally a good recommendation for older adults to maintain their strength and energy levels. However, it’s not directly related to the client’s current symptoms of confusion and disorientation.

Choice E rationale: Determining if the client has recently experienced a fall is important. Falls in older adults can lead to injuries, such as a head injury, which can cause confusion and other changes in mental status. Additionally, some medications used to treat pain after a fall can also contribute to confusion.

A. Phototherapy B. Administration of lithium C. Consciousness-raising D. Cognitive behavioral therapy E. Animal therapy F. Electroconvulsive therapy

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

Explanation

A) Incorrect - Phototherapy, often used to treat conditions like seasonal affective disorder (SAD) or certain skin conditions, involves exposure to specific wavelengths of light. It is not typically used as a treatment for distressing thoughts and memories related to trauma, as described in the client's situation.
B) Incorrect - Lithium is primarily used to treat bipolar disorder and is not a first-line treatment for trauma-related symptoms or acute stress disorder. The client's symptoms are more indicative of trauma-related distress, which would be addressed through psychotherapeutic approaches like cognitive behavioral therapy (CBT).
C) Incorrect - "Consciousness-raising" is not a recognized treatment intervention in this context.

It's important to focus on evidence-based therapeutic approaches for trauma-related symptoms, such as psychotherapy and support services.
D) Correct - Cognitive behavioral therapy (CBT) is Given the client's distressing thoughts and memories, CBT is a highly effective psychotherapy approach. It focuses on identifying and modifying negative thought patterns and behaviors associated with trauma. CBT can help the client develop healthier coping strategies.
E) Correct - Animal-assisted therapy involves interacting with trained animals to improve emotional well-being. Since the client expresses feeling unhappy and having difficulty coping, animal therapy can provide comfort, reduce stress, and promote a sense of companionship.
F) Incorrect - Electroconvulsive therapy (ECT) is a treatment primarily used for severe cases of depression or certain psychiatric conditions that are unresponsive to other treatments. It involves inducing controlled seizures to affect brain chemistry. ECT is not a first-line treatment for the client's distressing thoughts and memories following a traumatic event.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

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

Explanation

Patient Data What other treatments might be helpful for this client? Select all that apply.

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

Explanation

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important?

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)]

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?

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?