A nurse in an emergency department (ED) is caring for a client

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for correct choices:

Hyperthyroidism: The client presents with classic signs of hyperthyroidism or thyroid storm: heat intolerance, tremors, tachycardia, palpitations, agitation, insomnia, weight loss despite good appetite, diarrhea, and recent illness (influenza) acting as a trigger. These symptoms indicate an acutely increased metabolic state.
Place client on telemetry: Tachycardia and palpitations suggest cardiac involvement. Continuous cardiac monitoring helps detect life-threatening arrhythmias, such as atrial fibrillation, which are common in hyperthyroid crises.
Initiate hydration therapy: Hypermetabolism, fever, and diarrhea can cause fluid loss and increase the risk for dehydration. Hydration supports perfusion and reduces cardiac strain during a hypermetabolic state.
Cardiac dysrhythmias: Excess thyroid hormones increase the heart's sensitivity to catecholamines, heightening the risk for dysrhythmias. Monitoring rhythm helps identify complications early.
Neurological status: Agitation, tremors, and insomnia may progress to delirium or seizures in thyroid storm. Regular neuro checks allow early recognition of worsening symptoms.

Rationale for incorrect choices:

Hypoparathyroidism: This typically presents with signs of hypocalcemia such as tetany or paresthesias, not the metabolic hyperactivity seen here. The client's symptoms do not reflect this condition.
Hyperparathyroidism: It usually causes hypercalcemia, bone pain, and kidney stones, none of which are evident. Diarrhea, fever, and cardiac signs are not typical.
Hypothyroidism: Presents with fatigue, cold intolerance, constipation, bradycardia, and weight gain—opposite of this client’s hyperactive symptoms.
Check for Chvostek and Trousseau’s signs: These are used to assess for hypocalcemia, which is not indicated in this scenario. There are no neuromuscular irritability symptoms present.
Monitor for hypoglycemia: There's no indication of low blood sugar, and the client does not report symptoms like shakiness, confusion, or hunger related to hypoglycemia.
Provide nutritional support: While the client has lost weight, the priority is stabilizing the acute condition (thyroid storm), not nutritional rehabilitation at this moment.
Phosphorus levels: These are not directly affected in hyperthyroidism and monitoring them wouldn't provide information relevant to the current crisis.
Weight gain: This client has experienced weight loss, and tracking weight gain is not a relevant short-term indicator of improvement in acute hyperthyroidism.
Calcium levels: There is no evidence of calcium imbalance or parathyroid involvement, so monitoring calcium is not pertinent in this case.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Bilateral coarse, crackle breath sounds: These are common findings in pulmonary edema due to fluid accumulation in the lungs. Furosemide, a diuretic, helps reduce fluid overload, making it an appropriate medication to help improve these symptoms by promoting diuresis.

B. Vesicular breath sounds over the peripheral lung fields: Vesicular breath sounds are normal, and do not indicate the need for diuretics. The prescription for furosemide would be more appropriate if the client had signs of fluid overload, such as crackles.

C. Potassium 3.2 mEq/L (3.5 mEq/L to 5.0 mEq/L): This indicates hypokalemia. Since furosemide can cause potassium depletion, the nurse should verify the prescription and monitor the client’s potassium levels closely, as additional supplementation may be needed.

D. Blood pressure 100/70 mm Hg: This blood pressure is on the lower side of normal. While furosemide can lower blood pressure, this finding alone doesn't specifically indicate that the pulmonary edema is being effectively treated.

A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr B. A client who is immobile and has had an episode of urinary incontinence C. A client who has COPD and an oxygen saturation of 99% D. A client who has a concussion and has developed aphasia

Correct Answer is D

Explanation

A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.

B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.

C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.

D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.

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

A nurse is caring for a client who has pulmonary edema and a new prescription for furosemide 40 mg IV twice daily. Which of the following client findings indicates the prescription is appropriate?

Correct Answer is A

Explanation

A nurse is caring for a group of clients on a medical unit. For which of the following clients should the nurse intervene immediately?

Correct Answer is D

Explanation

A nurse is preparing to administer 30 units of NPH and 10 units of regular insulin to a client. Which of the following actions should the nurse take?

A nurse manager is evaluating a quality improvement initiative for reducing health care-associated infections. Which of the following findings indicate the initiative is effective?

A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report?

A nurse is planning teaching about methods to reduce incontinent episodes for a client who has stress incontinence. Which of the following Instructions should the nurse plan to include?

A nurse is teaching a client about the manifestations of menopause. Which of the following findings should the nurse include?