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A nurse is caring for a client.

Exhibits

Drag words from the choices below to fill in each blank in the following sentence.

The nurse is assessing the client. The client's

and are the priority findings.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"A"}

Rationale for Correct Choices:

  • Heart rate: The client’s heart rate has increased from 58/min to 118/min, indicating possible thyrotoxicosis or over-replacement of levothyroxine. Tachycardia is a priority finding because it can lead to cardiovascular complications such as arrhythmias or chest pain.
  • Pain: The client reports chest pain, which, combined with tachycardia and elevated blood pressure, may indicate cardiac strain or complications. Prompt assessment of pain helps identify potential cardiovascular compromise requiring urgent intervention.

Rationale for Incorrect Choices

  • Weight: While notable changes in weight are important for monitoring thyroid treatment, they are not immediately life-threatening compared with tachycardia and chest pain.
  • Skin: Skin changes provide supportive assessment information but are less immediately critical than cardiovascular status.
  • Temperature: Elevated temperature indicates hypermetabolism or possible infection, but it is not as immediately life-threatening as the tachycardia and chest pain.
  • Bowel sounds: Hyperactive bowel sounds reflect increased GI motility but are less urgent compared with cardiovascular and metabolic indicators.


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Related Questions

Correct Answer is D

Explanation

A. Administer the injection IM: Insulin should be administered subcutaneously, not intramuscularly, because IM injections can lead to faster absorption and increase the risk of hypoglycemia.

B. Roll the vial to mix the particulate matter within the suspension: Regular insulin is a clear solution and does not contain particulate matter, so rolling the vial is unnecessary. Only cloudy or suspension insulins, like NPH, require gentle mixing.

C. Draw up the insulin with a U-500 syringe: U-500 syringes are reserved for clients requiring very high insulin doses. Most standard doses of regular insulin are drawn using U-100 syringes, and using a U-500 syringe unnecessarily increases the risk of dosing errors.

D. Verify the dosage with another nurse: Verification by another nurse is a critical safety step, particularly for high-alert medications like insulin. It helps prevent dosing errors and ensures safe administration to the client.

Correct Answer is D

Explanation

A. Weight gain: Ergotamine does not typically cause weight gain. Its primary adverse effects are related to vascular and neuromuscular systems rather than metabolic changes.

B. Constipation: Constipation is not a common adverse effect of ergotamine. The medication primarily affects smooth muscle in blood vessels rather than gastrointestinal motility.

C. Hypoglycemia: Ergotamine does not influence blood glucose levels, so hypoglycemia is not an expected adverse effect.

D. Muscle pain: Ergotamine can cause vasoconstriction of peripheral blood vessels, which may lead to muscle pain, weakness, or tingling in the extremities. This neuromuscular effect is a recognized potential adverse effect of the medication.

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