A nurse is assisting with the care of a client.

Vital Signs.

1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.

Respiratory rate 16/min.

Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.

Temperature 37 °C (98.6 °F) Heart rate 112/min.

Respiratory rate 20/min.

Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.

Temperature 38.3 °C (101 °F) Heart rate 152/min.

For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.

Each finding may support more than 1 disease process.

Choice A rationale:

"Nervousness." Rationale: This is a correct instruction. Thyrotoxicosis is a condition characterized by excessive thyroid hormone production. Common symptoms include nervousness, anxiety, restlessness, and emotional instability. The client should notify the healthcare provider if they experience these symptoms as they may indicate an excessive dose of levothyroxine.

Choice B rationale:

"Cough." Rationale: Cough is not typically associated with thyrotoxicosis. Symptoms of thyrotoxicosis are primarily related to an overactive thyroid gland and may include palpitations, weight loss, heat intolerance, and nervousness.

Choice C rationale:

"Pruritus." Rationale: Pruritus (itching) is not a common symptom of thyrotoxicosis. Itchy skin is more likely related to other dermatological or systemic conditions and should be evaluated separately.

Choice D rationale:

"Polyuria." Rationale: Polyuria (excessive urination) can be associated with both hypothyroidism and hyperthyroidism, but it is not a typical manifestation of thyrotoxicosis. Increased urination is more commonly seen in conditions like diabetes mellitus. Therefore, polyuria alone may not be indicative of thyrotoxicosis in this context.

Choice A rationale:

Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.

Choice B rationale:

Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.

Choice C rationale:

Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.

Choice D rationale:

Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.