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A nurse is assisting with the care of a client in a provider's clinic.

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The client presents to clinic reporting a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well

Oriented ×4. Answers questions appropriately, follows simple commands Heart rate regular, S1 S2 auscultated. No abnormal heart sounds heard. Respiration even and unlabored. Lung sounds clear to auscultation. Abdomen soft, fat, normoactive bowel sounds in all four quad states, "appetite is good" and stools are soft and brown Reports voiding without difficulty, clear yellow urine. Reports last menstrual period was 3 months ago. Skin is warm and moist. Exophthalmus noted, goiter visualized on neck. Client’s partner reports that the client is imitable and anxious lately.

a 3-month history of unplanned weight loss, increased sweating and heat intolerance, and feeling fatigued and unable to sleep well

Reports last menstrual period was 3 months ago

Exophthalmus noted, goiter visualized on neck. Client’s partner reports that the client is imitable and anxious lately

Abdomen soft, fat, normoactive bowel sounds in all four quad states

No abnormal heart sounds heard

Answer and Explanation

The Correct Answer is ["A","B","C"]

3-month history of unplanned weight loss, increased sweating, heat intolerance, fatigue, and difficulty sleeping: These symptoms are classic for hyperthyroidism and suggest worsening metabolic imbalance. They require follow-up because untreated hyperthyroidism can lead to serious complications like thyroid storm.
Reports last menstrual period was 3 months ago: Amenorrhea or menstrual irregularities are common in hyperthyroidism due to hormonal disruption. This finding supports the diagnosis and needs follow-up for endocrine and reproductive health management.
Exophthalmos noted: Exophthalmos, or bulging eyes, is associated with Graves' disease and indicates autoimmune involvement affecting the orbital tissues. It can lead to complications like corneal ulceration or vision loss if severe and thus requires ophthalmologic evaluation.
Goiter visualized on neck: A visible goiter reflects thyroid gland enlargement, often due to hyperstimulation from excess thyroid hormones. It requires ongoing monitoring to assess for airway compromise, dysphagia, or further gland enlargement.
Client’s partner reports irritability and anxiety: Behavioral and mood changes like irritability and anxiety are manifestations of hyperthyroidism affecting neurological function. Persistent symptoms can impair quality of life and must be addressed as part of comprehensive treatment planning.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Cantaloupe: Cantaloupe is considered high in potassium, with about 430 mg of potassium per cup. This makes it unsuitable for a client needing a low-potassium diet, as it can significantly contribute to elevated potassium levels.

B. Sweet potato: Sweet potatoes are very high in potassium, containing around 540 mg of potassium per half-cup serving. They are not recommended for individuals trying to manage or lower their potassium intake.

C. Orange juice: Orange juice provides approximately 500 mg of potassium per 1-cup serving. It is commonly avoided or limited in potassium-restricted diets due to its significant contribution to total potassium intake.

D. Wheat bread: Wheat bread contains a relatively low amount of potassium, about 60 to 70 mg per slice. Compared to the other options listed, wheat bread is much lower in potassium and is a better choice for clients who need to restrict potassium in their diet.

A. Pain relieved by the prone position B. Decreased WBC count C. Hyperactive bowel sounds D. Epigastric pain

Correct Answer is D

Explanation

A. Pain relieved by the prone position: Pain from acute pancreatitis is typically not relieved by lying prone. Clients often find some relief by sitting up, leaning forward, or assuming a fetal position, as these positions reduce pressure on the inflamed pancreas.

B. Decreased WBC count: Acute pancreatitis usually triggers an inflammatory response, leading to an elevated white blood cell (WBC) count, not a decreased one. Leukocytosis is a common laboratory finding associated with the body's reaction to inflammation and possible infection.

C. Hyperactive bowel sounds: In acute pancreatitis, bowel sounds are often decreased or absent due to paralytic ileus. Hyperactive bowel sounds would be more suggestive of other gastrointestinal disturbances such as diarrhea or early intestinal obstruction.

D. Epigastric pain: Severe, persistent epigastric pain that may radiate to the back is the hallmark symptom of acute pancreatitis. This pain is typically sudden in onset and worsens after eating or drinking, especially fatty foods.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the low in potassium?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has acute pancreatitis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is reviewing the electronic health record (EHR) of a client who has type 2 diabetes mellitus. Which of the following findings in the client EHR should the nurse identify as a risk factor for type 2 diabetes mellitus?

A nurse is assisting with the care of a client who last used heroin 8 hr ago. Which of the following findings should the nurse identify as a manifestation of opioid withdrawal?

A nurse is discussing the components of the working phase of the nurse-client relationship with a client. Which of the following tasks are specific for this stage to create a therapeutic environment?

A nurse is caring for a client who has Clostridium difficile. When applying a cover gown, which of the following techniques should the nurse use?

A nurse is assisting in the discharge planning of an infant who has a spica cast. Which of the following equipment needs should the nurse identify for discharge?

A nurse is caring for a client who suddenly develops chest pain and dyspnea. Which of the following actions should the nurse take first

A nurse is assisting with the care of a client who has delirium. The client is disoriented and restless. Which of the following conditions should the nurse identify as a risk factor for delirium?