A nurse in the emergency department is caring for a female client brought to the ER by family for fatigue.

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:

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.

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Correct Answer is A

Explanation

A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.

A. Assess the client's respiratory status and airway patency. B. Assess the client's extremity strength and sensation. C. Assess the client's pain level and provide pain management. D. Assess the client's level of consciousness and orientation.

Correct Answer is A

Explanation

A. Assessing respiratory status and airway patency is the highest priority in this situation due to the risk of respiratory compromise from cervical spinal cord injuries, which can affect the diaphragm and other respiratory muscles.
B. While assessing extremity strength and sensation is important, it comes after ensuring the client’s airway and breathing are stable.
C. Pain management is essential, but addressing immediate life-threatening conditions takes precedence over pain assessment.
D. Assessing the client's level of consciousness is crucial for overall evaluation but does not take priority over ensuring adequate respiratory function in the context of a cervical spinal cord injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

Correct Answer is A

Explanation

A nurse is in the emergency department (ED) and is caring for a client that has arrived by ambulance after a cervical spinal cord injury. Which assessment should be the priority for the nurse to perform at this time?

Correct Answer is A

Explanation

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

A nurse is caring for a client who had a brain tumor and chemotherapy as an infant. The assessment reveals short stature and delayed onset of menarche. The nurse recognizes the assessed problems are most likely caused by which of the following?

A nurse is assessing a client diagnosed with diabetes insipidus. The nurse should expect which of the following assessment findings?

A nurse is caring for a client newly diagnosed with hyperthyroidism. The nurse recognizes that which of the following is a potential severe complication of hyperthyroidism?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? Select all that apply.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

A client is admitted for treatment of the Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The nurse should initiate which of the following interventions?