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: Lethargy and lack of appetite are symptoms that might indicate hypothyroidism or an insufficient dosage of levothyroxine. These symptoms are not typically associated with a dosage that is too high.

Choice B reason: Bradycardia and constipation are also indicative of hypothyroidism or an inadequate dosage of levothyroxine. These symptoms suggest a need for a higher dosage rather than indicating that the current dosage is too high.

Choice C reason: Muscle cramping and dry, flushed skin can be associated with electrolyte imbalances or dehydration, but they are not specific symptoms of an excessive dosage of levothyroxine.

Choice D reason: Palpitations and shortness of breath are signs of hyperthyroidism, which can occur if the dosage of levothyroxine is too high. These symptoms indicate that the client's metabolism is excessively stimulated, leading to cardiovascular strain and respiratory distress. It is crucial for the nurse to monitor these symptoms and adjust the medication dosage accordingly.

A. "You will feel drowsy for several hours after surgery." B. "You will need to get out of bed the day after surgery." C. "Your clear liquid diet will include gelatine and tea." D. "Your bowel sounds will be assessed every four hours."

Correct Answer is B

Explanation

Choice A reason: Informing the client that they will feel drowsy for several hours after surgery is important for setting realistic expectations about the immediate postoperative period. However, it is not the most critical information to ensure adherence to the postoperative regimen.

Choice B reason: It is essential to inform the client about the importance of early mobilization, which involves getting out of bed the day after surgery. Early mobilization helps prevent complications such as deep vein thrombosis (DVT), pulmonary embolism, and pneumonia. Emphasizing this information preoperatively ensures that the client understands the necessity of moving and participating in their recovery process, which is vital for successful postoperative outcomes.

Choice C reason: Explaining the components of a clear liquid diet, including gelatine and tea, is helpful for the client to know what to expect in terms of dietary modifications. However, it is not as critical as informing the client about early mobilization, which has a direct impact on their recovery and prevention of complications.

Choice D reason: Informing the client that their bowel sounds will be assessed every four hours is part of routine postoperative care. While it is important for the client to understand the monitoring process, it is not the most crucial aspect to ensure adherence to the postoperative regimen. Early mobilization has a more significant impact on the client’s overall recovery.

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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

A 26-year-old client is admitted to the hospital for treatment of a simple goitre, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

Correct Answer is D

Explanation

To ensure client adherence to the postoperative regimen, which content is most important for the nurse to include in the preoperative teaching?

Correct Answer is B

Explanation

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