A home health nurse is assessing a client who requires lifelong replacement hormone therapy for hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect?

Increased urine output.

Persistent diarrhea.

Hypotension.

Tachycardia.

Answer and Explanation

The Correct Answer is C

Choice A reason: Increased urine output is not typical in untreated hypothyroidism, which slows metabolism and fluid balance. Hypotension from reduced cardiac output is expected, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in a client non-compliant with hypothyroidism therapy.

Choice B reason: Persistent diarrhea is more associated with hyperthyroidism, not hypothyroidism, which causes constipation. Hypotension is a common finding in untreated hypothyroidism, making this incorrect, as it contradicts the expected symptoms in the nurse’s assessment of the non-compliant client.

Choice C reason: Hypotension is expected in untreated hypothyroidism due to decreased metabolic rate and cardiac output. This aligns with endocrine assessment findings, making it the correct finding the nurse would anticipate in a client who hasn’t taken thyroid replacement medication regularly.

Choice D reason: Tachycardia is typical in hyperthyroidism, not hypothyroidism, which causes bradycardia. Hypotension is more consistent with untreated hypothyroidism, making this incorrect, as it doesn’t reflect the slowed metabolism expected in the nurse’s evaluation of the non-compliant client.

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

Explanation

Choice A reason: Diarrhea is less common in acute pancreatitis, which typically causes nausea and vomiting. Flank discoloration is a specific sign, making this incorrect, as it’s not a primary finding the nurse would expect in the assessment of acute pancreatitis.

Choice B reason: Black tarry stools indicate upper GI bleeding, not pancreatitis, which causes pain and guarding. Left quadrant pain is typical, making this incorrect, as it’s unrelated to the nurse’s expected findings in a client with suspected acute pancreatitis.

Choice C reason: Hyperactive bowel sounds suggest obstruction, not pancreatitis, which often causes hypoactive sounds due to inflammation. Abdominal tenderness is correct, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in acute pancreatitis assessment.

Choice D reason: Gray, including its reasoning, and a gray-blue flank (Cullen’s or Grey Turner’s sign) indicates severe pancreatitis with hemorrhage. This aligns with severe pancreatitis assessment, making it a correct finding the nurse would expect in suspected acute pancreatitis.

Choice E reason: Abdominal guarding and tenderness result from pancreatic inflammation, common in acute pancreatitis. This aligns with abdominal assessment findings, making it a correct manifestation the nurse would identify in a client with suspected acute pancreatitis.

Choice F reason: Left upper quadrant pain radiating to the back is classic in acute pancreatitis due to pancreatic inflammation. This aligns with clinical assessment, making it a correct finding the nurse would expect in a client with suspected acute pancreatitis.

A. Client whose deep tendon reflexes have become hyperactive. B. Client who displays plantar flexion when the bottom of the foot is stroked. C. Client who consistently demonstrates decortication when stimulated. D. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 10.

Correct Answer is D

Explanation

Choice A reason: Hyperactive reflexes suggest neurological irritability but are less urgent than a GCS drop from 15 to 10, indicating deteriorating consciousness. This is incorrect, as it’s lower priority than the nurse’s focus on a client with a significant neurological decline.

Choice B reason: Plantar flexion (Babinski sign) may indicate neurological issues, but a GCS drop to 10 signals acute deterioration, requiring immediate attention. This is incorrect, as it’s less critical than the nurse’s priority to assess the client with a declining GCS.

Choice C reason: Decortication indicates severe brain injury but, if consistent, is less acute than a GCS drop from 15 to 10, suggesting rapid worsening. This is incorrect, as it’s not the nurse’s first priority compared to the client with acute neurological change.

Choice D reason: A GCS drop from 15 to 10 indicates a significant decline in consciousness, a neurological emergency requiring immediate assessment. This aligns with neurosurgical priorities, making it the correct client for the nurse to prioritize on the unit.

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A home health nurse is assessing a client who requires lifelong replacement hormone therapy for hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

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

Explanation

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Correct Answer is D

Explanation

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