A nurse in an emergency department (ED) is caring for a client
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Metabolic alkalosis: In metabolic alkalosis, the pH is elevated (above 7.45), and the bicarbonate (HCO3) is increased (above 28 mEq/L). In this scenario, the pH is low (7.12), and HCO3 is low (20 mEq/L), which is not consistent with alkalosis.
B. Metabolic acidosis: In metabolic acidosis, the pH is low (below 7.35), and the bicarbonate (HCO3) is low (below 21 mEq/L), which is consistent with the client's ABG values (pH 7.12, HCO3 20 mEq/L). This suggests the client has metabolic acidosis, which is common in chronic kidney failure due to impaired excretion of acid and decreased bicarbonate.
C. Respiratory acidosis: In respiratory acidosis, the pH is low, and the PaCO2 is elevated (above 45 mm Hg). The PaCO2 in this client is within the normal range (40 mm Hg), making respiratory acidosis unlikely.
D. Respiratory alkalosis: In respiratory alkalosis, the pH would be high, and the PaCO2 would be low (below 35 mm Hg). The client's pH is low (7.12), and the PaCO2 is normal, so respiratory alkalosis is not present.
Correct Answer is B
Explanation
A. "Restrict your partner's oral fluid intake to 450 mL/day.": Fluid restriction in ESKD should be individualized based on the client’s kidney function and retention. A strict 450 mL/day limit is not universally applicable.
B. "Limit your partner's potassium intake to 60 mEq/L per day.": Potassium intake is typically restricted in ESKD due to the kidneys' reduced ability to excrete it. The appropriate restriction depends on potassium levels, but generally, it’s advised to limit intake to prevent hyperkalemia and related complications.
C. "Help your partner consume foods containing phosphorus.": Phosphorus intake should be restricted in ESKD, as high phosphorus levels can cause complications like bone disease. Consuming phosphorus-rich foods should be avoided to prevent calcium-phosphorus imbalances and calcification.
D. "Encourage foods high in protein for your partner.": Excess protein intake in ESKD can exacerbate kidney function decline and increase waste buildup. Protein intake should be monitored and reduced to minimize the kidneys’ workload and prevent further damage.
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