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 C

Explanation

Choice A reason: The degree of skin elasticity is a measure often used to assess hydration status, especially in older adults. However, it does not provide direct information about the client's cardiac function or the cause of their current symptoms.

Choice B reason: The length of capillary refill is useful for assessing peripheral perfusion and overall circulatory status. While prolonged capillary refill can indicate poor perfusion, it does not provide specific information about heart rhythm or the cause of palpitations and faintness in a client with heart failure.

Choice C reason: The rhythm of the apical pulse is the most important assessment data to obtain in this scenario. The client's complaint of a fast-beating heart and feeling faint suggests a possible arrhythmia, which could be detected by assessing the rhythm of the apical pulse. This assessment can help identify irregular heartbeats, tachycardia, or other abnormalities that may require immediate intervention.

Choice D reason: The volume of pedal pulses can provide information about peripheral circulation, but it is not as crucial as assessing the heart rhythm in a client experiencing palpitations and faintness. Peripheral pulse volume may not change significantly with certain arrhythmias or cardiac issues that affect the central circulation more directly.

A. Decrease dietary fat intake. B. Increase fluids and dietary fibber. C. Ingest frequent small meals. D. Reduce roughage in the diet.

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.

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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?

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Naxlex Comprehensive Predictor Exams

A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, "My heart feels like it is beating too fast and I feel faint." After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

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