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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Lie down when taking the medication: Sublingual nitroglycerin causes vasodilation, which can lower blood pressure and potentially cause dizziness or fainting. The client should lie down or sit in a comfortable position to minimize the risk of falls or injury.

B. Chew the medication thoroughly: Sublingual nitroglycerin should be placed under the tongue and allowed to dissolve completely, not chewed. Chewing may affect the absorption and effectiveness of the medication.

C. Store the medication in the refrigerator: Sublingual nitroglycerin should be stored at room temperature, away from moisture and heat, not in the refrigerator. Cold storage could reduce the medication's effectiveness.

D. Check the expiration date on the medication every 6 months: While it is important to check the expiration date, every 6 months is not sufficient. The client should check the expiration date more frequently (e.g., every 3 months) and replace the medication if expired to ensure it is effective when needed.

A. Oxygen saturation B. Blood pressure C. Pain level D. Hematocrit E. Temperature F. Activity level G. Breath sounds

Correct Answer is ["A","B","D","F"]

Explanation

Rationale for Correct Choices:

Oxygen saturation: The client's oxygen saturation is 94% on room air. While not critically low, given their reported shortness of breath and fatigue, this warrants follow-up. It could be indicative of the severity of their anemia impacting oxygen delivery.
Blood pressure: The client shows signs of orthostatic hypotension, with a significant drop from 132/60 mm Hg (supine) to 102/50 mm Hg (standing). This change can cause dizziness, falls, and worsened fatigue, and it may be related to anemia or volume depletion that needs evaluation.
Hematocrit: A hematocrit of 24% is critically low, indicating significant anemia. This aligns with the client’s symptoms of fatigue and dyspnea and requires prompt intervention to determine the underlying cause, such as iron or B12 deficiency.
Activity level: The client reports shortness of breath with minimal exertion and difficulty keeping up with grandchildren. This functional decline reflects impaired oxygen delivery due to anemia and must be addressed as it affects quality of life and safety.

Rationale for Incorrect Choices:

Pain level: The client reports no pain or discomfort at this time. While pain is common in rheumatoid arthritis, the current lack of pain does not require further assessment or intervention.
Temperature: The client's temperature is 37°C (98.6°F), which is normal. There are no signs of infection or inflammation requiring follow-up based solely on this vital sign.
Breath sounds: Bilateral clear breath sounds indicate that the lungs are not congested and there is no evidence of pulmonary pathology at this time. Therefore, this finding does not require follow-up.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has angina about sublingual nitroglycerin. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse in a provider's office is caring for a client. Exhibits Which of the following findings require follow-up? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

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