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

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

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.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne diseases like tuberculosis or measles, where pathogens are airborne. VRE is a contact-transmitted infection, not airborne, so a negative pressure room is not necessary.

B. Wear a gown and gloves during client interactions and care: VRE is spread through direct contact with contaminated surfaces or bodily fluids. Wearing a gown and gloves provides the necessary precautions to prevent the spread of the infection through contact transmission.

C. Wear a surgical mask during client interactions and care: A surgical mask is primarily used for droplet precautions (e.g., influenza), not for contact precautions like VRE. A mask is not necessary unless the client has a respiratory infection or if there is a risk of splashing bodily fluids.

D. Place the client in a room with high-efficiency particulate air (HEPA) filtration for incoming air: HEPA filtration is used for airborne infections such as tuberculosis. Since VRE is not an airborne pathogen, this measure is unnecessary for preventing the spread of VRE.

A. Erythema B. Blood C. Edema D. Pruritus

Correct Answer is C

Explanation

A. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who is on isolation for an infection with vancomycin-resistant enterococcus (VRE). Which of the following actions should the nurse take to prevent the spread of infection?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

Correct Answer is C

Explanation

The nurse has reviewed the Vital Signs at 1000. Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

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A nurse is collecting data from a client who is at 35 weeks of gestation. Which of the following findings should the nurse report to the provider?

A nurse is using the assistance of an interpreter to reinforce discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take when working with an interpreter?

A nurse is reinforcing teaching with a client who is scheduled for a thoracentesis. Which of the following information should the nurse in the teaching?

A nurse is collecting data from a client who is 2 days postoperative following abdominal surgery. Which of the following findings is a manifestation that can indicate an infection?

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