A nurse in the emergency department is caring for a female client brought to the ER by family for fatigue.
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:
- Potential Condition: Hypothyroidism - The client exhibits signs consistent with hypothyroidism, including fatigue, weight gain, decreased appetite, hair loss, constipation, and intolerance to cold. The laboratory results show low serum T3 and T4 levels, confirming this diagnosis.
- Actions to Take:
- Request a prescription for Thyroid hormone replacement: This is crucial for managing hypothyroidism and restoring normal metabolic function.
- Administer supplemental oxygen: Given the client’s low oxygen saturation (92%), this intervention is essential to ensure adequate oxygen delivery and prevent further complications.
- Parameters to Monitor:
- Bowel function: Monitoring bowel habits is important since constipation is a common symptom of hypothyroidism, and managing this aspect can improve the patient's overall comfort and health.
- Oxygen saturation: Continuous assessment of oxygen levels is necessary to address the patient's respiratory needs and detect any further deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Feeling fatigued is not indicative of a therapeutic response; rather, patients should experience increased energy levels with appropriate therapy.
B. Decreased thyroxine levels are not the primary goal of levothyroxine therapy, which aims to normalize thyroid hormone levels in the body.
C. Decreased thyroid-stimulating hormone (TSH) levels indicate that the body is responding well to levothyroxine, as TSH production decreases when thyroid hormone levels are adequate.
D. Bradycardia and hypotension are not desired effects of levothyroxine and indicate potential under-treatment or other issues rather than a therapeutic response.
Correct Answer is A
Explanation
A. In SIADH, excess ADH causes water retention and hyponatremia; fluid restriction helps to prevent further dilution of sodium and manage fluid balance.
B. NPO status is unnecessary unless otherwise indicated; managing fluid intake is more effective.
C. Increasing oral intake would worsen fluid overload and hyponatremia.
D. Rapid IV fluid infusion can exacerbate the client’s condition by increasing fluid volume further.
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