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A nurse is caring for a patient in the endocrinologist outpatient clinic.

Exhibits

When completing the assessment at 0810, which of the findings listed below would require a follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 100.5° F

Heart rate 105/min

Respiratory rate 18/min

The client is 34 years of age. States she has a bowel movement after every meal, heat intolerance, and nervousness. The client has lost 20 pounds in the last month without dieting or a change in physical activity. She exercises 4-5 times per week for 45 minutes at a time. States at times during exercise, she experiences irregular heartbeat.

Axillary temperature 100.5° F

Heart rate 105/min

States she has a bowel movement after every meal

heat intolerance, and nervousness

nervousness

The client has lost 20 pounds in the last month without dieting or a change in physical activity

she experiences irregular heartbeat

States at times during exercise

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

The increase in axillary temperature to 100.5° F is significant and could indicate an infection or other inflammatory process. The heart rate has increased to 105/min, which, along with the reported symptoms of heat intolerance, nervousness, and irregular heartbeat during exercise, may suggest an endocrine disorder such as hyperthyroidism. The significant weight loss of 20 pounds in a month without changes in diet or physical activity is also concerning and warrants further investigation. The patient's history of having a bowel movement after every meal could be related to the reported diarrhea and should be explored further.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Hydrochlorothiazide is known to increase blood glucose levels, particularly in clients with diabetes or those at risk for glucose intolerance.

B. Dysrhythmias are more commonly associated with electrolyte imbalances like low potassium, but elevated glucose is more specific to hydrochlorothiazide use.

C. Hydrochlorothiazide typically lowers blood pressure, so elevated blood pressure is not a common nontherapeutic response.

D. Impaired airway is unrelated to hydrochlorothiazide use.

A. Prepare the client for hemodialysis. B. Initiate safety precautions to protect the client from injury. C. Administer to the client prescribed calcium supplement. D. Assess the client for tetany. E. Educate the client to avoid foods that are high in calcium.

Correct Answer is ["B","C","D"]

Explanation

A. Hemodialysis is not indicated for a low calcium level unless associated with severe renal failure or other metabolic disturbances.

B. Safety precautions are important due to the risk of fractures or injury caused by weakened bones and muscle spasms related to hypocalcemia.

C. Administering prescribed calcium supplements is a key intervention to correct hypocalcemia.

D. Tetany, a sign of severe hypocalcemia, should be assessed as it can lead to muscle cramps and spasms.

E. Educating the client to avoid foods that are high in calcium would not be appropriate, as the client requires calcium to address the low levels.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving the diuretic hydrochlorothiazide. When evaluating the client's response to hydrochlorothiazide, which common nontherapeutic response is important for the nurse to monitor?

Correct Answer is A

Explanation

A nurse in the outpatient clinic is caring for a client with a serum calcium level of 7.5 mg/dL (8.5-10.2 mg/dL). What nursing intervention is most important when providing care for this client? (Select All That Apply).

Correct Answer is ["B","C","D"]

Explanation

A nurse in the community clinic is providing care to a client who is anxious and hyperventilating. What should the nurse do to reduce the risk of respiratory alkalosis?

The nurse is caring for a client on the neurologic medical-surgical unit who was admitted for a new onset of cerebrovascular attack. The client has a medical history of hypertension and diabetes. While conducting a neurologic assessment, how should the nurse assess the oculomotor nerve?

A nurse has been assigned four patients of which one of the patients is completely immobile. Which complication should the nurse expect as a result of immobility? (Select all that apply.)

The nurse is admitting a client to the urgent care center. When taking a health history of an older adult client, the nurse would inquire about a history of which eye conditions. Select the four options that apply.

The nurse is developing a plan of care for a client who will be admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis (DVT) of the right leg. What should be included in the client's care plan?

The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

The nurse is collecting a medical history on a 34-year old client. The client reports: "I take oral antibiotics whenever she gets a sore throat, because she cannot afford to lose any time at work". What is the nurse's best response?