A client with hyperthyroidism tells the home health nurse, "I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding." Which assessment is most important for the nurse to obtain?

Peripheral pulses.

Vital signs.

Presence of goitre.

Emotional status.

Answer and Explanation

The Correct Answer is B

Choice A reason: Assessing peripheral pulses is important for understanding the client's overall circulatory status, but it is not the most urgent assessment in this situation. The client's symptoms suggest a possible thyrotoxic crisis, which requires immediate evaluation of critical vital signs.

Choice B reason: Obtaining vital signs is the most important initial assessment. The client's report of anxiety, heart racing, and pounding could indicate a severe exacerbation of hyperthyroidism, potentially leading to a thyrotoxic crisis (thyroid storm). Vital signs will provide essential information on the client's heart rate, blood pressure, temperature, and overall stability, which are crucial for immediate management.

Choice C reason: The presence of a goitre can indicates thyroid gland enlargement, which is relevant for long-term management of hyperthyroidism. However, it does not provide immediate information on the client's current acute condition.

Choice D reason: Assessing emotional status is important for comprehensive care, but it is not the priority in this acute scenario. The client's physiological status needs to be stabilized first, as indicated by their vital signs, before focusing on their emotional state.

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Correct Answer is D

Explanation

Choice A reason: Decreasing dietary fat intake can be beneficial for overall health, but it is not specifically related to managing diverticulitis. Dietary fat does not directly influence the inflammation of diverticula.

Choice B reason: Increasing fluids and dietary fibber is important for preventing diverticulosis, which is the presence of diverticula in the colon. However, during an acute episode of diverticulitis, high fibber can exacerbate symptoms. Therefore, this recommendation is not appropriate during active inflammation.

Choice C reason: Ingesting frequent small meals can aid in digestion and prevent large meals from causing discomfort, but it does not directly address the dietary needs during diverticulitis.

Choice D reason: Reducing roughage in the diet is crucial during an acute episode of diverticulitis. High-fibber foods and roughage can irritate the inflamed diverticula and worsen symptoms. A low-fibber diet is often recommended until the inflammation subsides, after which a gradual return to a high-fibber diet can be beneficial to prevent future episodes.

A. Leave the door open so she recognizes her belongings. B. Place a picture of the client on her door. C. Put a bright red balloon on the client's door. D. Enlarge the letters of her name on the door.

Correct Answer is B

Explanation

Choice A reason: Leaving the door open so the client recognizes her belongings might help, but it is not the most effective solution. It relies on the client being able to remember and identify her possessions, which can be challenging with Alzheimer's disease.

Choice B reason: Placing a picture of the client on her door is an effective intervention. It provides a clear visual cue that the client can easily recognize, helping her to identify her own room without relying on memory alone. This approach uses a personal and familiar image, making it easier for the client to find her room.

Choice C reason: Putting a bright red balloon on the client's door may attract attention but does not provide a personal or meaningful cue for the client. While it might help distinguish the door, it lacks the personal connection needed for effective recognition.

Choice D reason: Enlarging the letters of her name on the door can help, but it still relies on the client's ability to read and recognize her name, which may be impaired. A picture of the client is a more straightforward and effective visual aid.

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A client with hyperthyroidism tells the home health nurse, "I stopped taking my antithyroid medication and now I feel anxious. I can feel my heart racing and pounding." Which assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which diet modification should the nurse suggest to a client who was recently diagnosed with diverticulitis?

Correct Answer is D

Explanation

An older female resident of a long-term care facility with early-stage Alzheimer's disease frequently wanders into the wrong room. To help this client recognize her room, which intervention should the nurse implement?

Correct Answer is B

Explanation

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