A nurse is planning care for a client who is experiencing thyroid storm triggered by a systemic infection. Which of the following interventions should the nurse plan to take?
Request a prescription for levothyroxine IV.
Administer supplemental oxygen to the client.
Cover the client with warm blankets.
Implement measures to increase the client's pulse rate.
The Correct Answer is D
A) "Limit sodium intake to 3,500 milligrams per day.":
Limiting sodium intake is crucial for managing heart failure to prevent fluid retention and exacerbation of symptoms. However, the recommended limit is typically much lower, around 1,500 to 2,000 milligrams per day, not 3,500 milligrams.
B) "Take ibuprofen for discomfort.":
Ibuprofen and other NSAIDs are not recommended for clients with heart failure as they can cause fluid retention, worsen heart failure symptoms, and increase the risk of kidney problems. Alternatives such as acetaminophen are generally safer for pain relief.
C) "Increase the distance you walk by 100 feet daily, even if you feel fatigued.":
While regular exercise is important, clients with heart failure should not push through fatigue, as overexertion can lead to worsening symptoms. Exercise recommendations should be tailored to the individual's tolerance and should be adjusted based on their energy levels.
D) "Include no more than 2,000 milliliters of fluid intake in 24 hours.":
Restricting fluid intake to 2,000 milliliters per day helps prevent fluid overload, which is critical for managing heart failure. Monitoring and limiting fluid intake can help control symptoms such as edema and shortness of breath.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Offer the client a small meal if she is not nauseated:
While eating a small meal can help raise blood glucose levels, it is not the immediate priority in a severe hypoglycemia situation. The client might be unconscious or unable to swallow safely, making this action inappropriate as a first step.
B) Administer 1 mg of glucagon intramuscularly to the client:
Administering glucagon intramuscularly is the most crucial initial action. Glucagon rapidly increases blood glucose levels by stimulating glycogen breakdown in the liver. This is vital for quickly reversing severe hypoglycemia, especially if the client is unconscious or unable to ingest carbohydrates orally.
C) Contact the client's provider for further instructions:
Contacting the provider is essential, but it should occur after addressing the immediate hypoglycemic episode. Once the client's condition stabilizes, further guidance can be sought from the healthcare provider.
D) Transport the client to an emergency department for treatment:
Transporting the client to the emergency department is necessary if the hypoglycemia does not improve after administering glucagon or if the client remains unresponsive. However, it is not the first action; immediate glucagon administration takes precedence to stabilize the client's condition before considering transportation.
Correct Answer is B
Explanation
A. Antimicrobial medication can decrease the severity of symptoms.: Antiviral medications, rather than antimicrobial ones, are used to reduce the severity and duration of herpes zoster (shingles). They work best when started within 72 hours of the rash appearing.
B. Postherpetic nerve pain can occur in older adult clients.: Postherpetic neuralgia (PHN) is a common complication of herpes zoster, especially in older adults. It is characterized by persistent pain in the area where the shingles rash occurred.
C. Lesions often occur inside the oral cavity of clients who have this infection.: Herpes zoster typically causes a painful rash that appears on one side of the body, often in a band or strip, rather than inside the oral cavity. Oral lesions are more characteristic of herpes simplex virus infections.
D. Cellulitis is a common manifestation in clients who have this infection.: Cellulitis is not a typical manifestation of herpes zoster. Herpes zoster is characterized by a vesicular rash and pain along a dermatomal distribution, not by cellulitis.
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