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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. Provide the client with low-calorie formula: The calorie content of the formula is not typically responsible for diarrhea. Diarrhea is more often related to formula intolerance, contamination, or rapid feeding rates rather than calorie density.

B. Increase the rate of the client's feeding: Increasing the rate can worsen diarrhea by overwhelming the gastrointestinal system, leading to poor absorption and increased fluid loss. Slower rates are often needed if diarrhea occurs.

C. Switch the client to a formula containing less protein: Protein content is usually not the cause of diarrhea. Specialized formulas may be needed for certain conditions, but protein itself is not typically a trigger for diarrhea.

D. Administer the client's formula at room temperature: Cold formula can cause gastric cramping and diarrhea. Administering the formula at room temperature helps reduce gastrointestinal irritation and promotes better tolerance of the feeding.

A. Dry skin B. Hypotension C. Constipation D. Urinary retention

Correct Answer is B

Explanation

A. Dry skin: Dry skin is not typically associated with the disulfiram-alcohol reaction. The primary concerns involve cardiovascular and gastrointestinal symptoms rather than dermatologic effects.

B. Hypotension: Disulfiram causes an intense physical reaction when alcohol is consumed, including symptoms like flushing, nausea, vomiting, hypotension, and potentially life-threatening cardiovascular collapse. Monitoring for hypotension is critical during this reaction.

C. Constipation: Constipation is not a typical side effect of disulfiram-alcohol interaction. Gastrointestinal symptoms such as nausea and vomiting are much more common and more clinically significant.

D. Urinary retention: Urinary retention is not a known reaction to the combination of disulfiram and alcohol. The body’s response focuses more on vascular changes and gastrointestinal distress.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous enteral tube feeding and develops diarrhea. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?

Correct Answer is B

Explanation

A nurse in a health clinic is assisting in the care of a client diagnosed with chlamydia. The client was prescribed azithromycin 1 g PO once. Which of following allergy findings in the client's history should the nurse report to the provider?

A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?

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

A nurse is assisting in the care of a client who is 48 hr postpartum. The client states, "My baby won't stop crying even though I've changed her diaper and breastfed her." Which of the following statements should the nurse make?

A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?

Which of the following findings requires further action by the nurse? Select all that apply.

A nurse is monitoring a young adult client for risk-taking behavior. Which of the following statements by the client indicates they are limiting their risk-taking behavior?