A nurse is assessing a patient admitted with hyperthyroidism.
The patient reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness.Which of the following actions should the nurse take to prevent a thyroid crisis?
Provide a quiet, low-stimulus environment
Keep the patient NPO
Administer aspirin as prescribed for any sign of hyperthermia.
Observe the patient carefully for signs of hypocalcemia.
The Correct Answer is A
Choice A rationale
Providing a quiet, low-stimulus environment is one of the key interventions for a patient with hyperthyroidism who is at risk of a thyroid crisis. Hyperthyroidism is characterized by an overproduction of thyroid hormones, which can accelerate the body’s metabolism causing symptoms such as rapid heart rate, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. A thyroid crisis, also known as a thyroid storm, is a severe, life-threatening condition characterized by extreme symptoms of hyperthyroidism. A quiet, low-stimulus environment can help reduce anxiety and agitation, which can exacerbate symptoms and potentially trigger a thyroid crisis.
Choice B rationale
Keeping the patient NPO (nothing by mouth) is not typically necessary in the management of hyperthyroidism unless the patient is preparing for a procedure such as thyroid surgery. In
fact, because of the increased metabolic rate in hyperthyroidism, patients often have an increased appetite and may require additional caloric intake.
Choice C rationale
Administering aspirin for any sign of hyperthermia is not recommended in hyperthyroidism. Aspirin can actually increase the level of free thyroid hormones in the blood by displacing them from their binding proteins, potentially worsening the hyperthyroid state.
Choice D rationale
While it is important to observe patients with hyperthyroidism for signs of various complications, hypocalcemia is not typically associated with hyperthyroidism. Hypocalcemia, or low calcium levels in the blood, is more commonly associated with hypoparathyroidism or vitamin D deficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While chronic exposure to UV rays can cause skin dryness, it does not decrease the water content of the skin20. Skin dryness is more of a symptom rather than a risk factor for skin cancer20.
Choice B rationale
Chronic exposure to UV rays can cause an error in the skin’s genetic code20. This can lead to the development of skin cancer, as the damaged DNA can lead to uncontrolled cell growth20.
Choice C rationale
Increased blood flow to the skin is not a direct result of chronic exposure to UV rays20. While UV rays can cause skin redness and inflammation, these are not directly linked to an increased risk of skin cancer20.
Choice D rationale
Chronic exposure to UV rays does not cause degeneration of elastic fibers in skin tissue20. While UV rays can cause skin aging and wrinkles, these are not direct risk factors for skin cancer20. Diabetic retinopathyDiabetic retinopathy Explore
Correct Answer is D
Explanation
Choice A rationale
While bleeding precautions are important in certain conditions, they may not be the priority for a patient with significant abdominal ascites. Ascites, the accumulation of fluid in the peritoneal cavity, is often caused by liver disease such as cirrhosis.
Choice B rationale
Skin safety protocols are important for all patients, but they may not be the priority in this case. Ascites can cause discomfort and other complications, but it does not directly cause skin problems.
Choice C rationale
A sodium restriction diet can be beneficial for patients with ascites, as it can help reduce fluid accumulation. However, this measure may not be the priority in this case.
Choice D rationale
Implementing a fall risk protocol should be prioritized. The patient’s significant abdominal ascites could affect their balance and mobility, increasing their risk of falls. Furthermore, the patient usually uses a cane for support but forgot to bring it to the hospital, further increasing their fall risk.
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