A nurse in the emergency department is caring for a female client with hyperthyroidism. After reviewing the assessment findings, which of the following findings require follow-up?
Potassium level
Oxygen saturation
Blood pressure and temperature 38.1 C 100.6F
Breath sounds
The Correct Answer is C
A. The potassium level of 3.6 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not require follow-up.
B. Oxygen saturation of 97% on room air is normal and does not indicate a concern.
C. Blood pressure of 168/70 mm Hg indicates systolic hypertension, and a temperature of 38.1°C (100.6°F) suggests a possible hypermetabolic state or impending thyroid storm in the setting of hyperthyroidism — this combination requires follow-up. These findings may indicate worsening hyperthyroidism or progression toward a life-threatening complication.
D. Clear and present bilateral breath sounds are normal and do not warrant follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A weight loss of 2.5 pounds, a decrease in heart rate, and improved lung sounds (crackles now fine and only in lower bases) indicate that diuresis is occurring and the heart failure is responding to treatment. These are signs of clinical improvement.
B. The findings show improvement, not failure of treatment, so more aggressive therapy is not indicated at this time.
C. There is no immediate need for reassessment by the provider as the client is improving.
D. The client’s condition has clearly improved since admission, showing that the condition is not unchanged.
Correct Answer is A
Explanation
A. Intramuscular vitamin B12 is the appropriate treatment for pernicious anemia, which results from the inability to absorb vitamin B12 due to lack of intrinsic factor — commonly seen after a Billroth-II procedure that alters the stomach's ability to produce this factor.
B. Folic acid deficiency causes a different type of anemia and is not the primary treatment for pernicious anemia.
C. Iron dextran is used to treat iron-deficiency anemia, not pernicious anemia.
D. Oral thiamine is used in conditions like Wernicke-Korsakoff syndrome, often related to chronic alcohol use, and is not indicated for pernicious anemia.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
