A nurse is reviewing laboratory results and notes that a client has an elevated thyroid-stimulating hormone (TSH) level. Which of the following assessment findings would the nurse expect?

Anxiety, unintended weight loss, palpitations

Fatigue, constipation, weight gain

Increased thirst, increased urine output, and weight los

Shakiness, sweating, nausea

Answer and Explanation

The Correct Answer is B

A. Anxiety, unintended weight loss, palpitations: These symptoms are consistent with hyperthyroidism, where excess thyroid hormone speeds up metabolism. Hyperthyroidism is typically associated with low TSH levels due to negative feedback suppression of the pituitary gland.
B. Fatigue, constipation, weight gain: These are classic symptoms of hypothyroidism, where a deficiency of thyroid hormones slows metabolic processes. An elevated TSH level reflects the pituitary's response to low circulating thyroid hormone, attempting to stimulate the thyroid to produce more.
C. Increased thirst, increased urine output, and weight loss: These symptoms point to hyperglycemia or conditions like diabetes mellitus, not thyroid dysfunction. They are due to glucose imbalances rather than altered thyroid hormone or TSH levels.
D. Shakiness, sweating, nausea: These symptoms are typically seen in hypoglycemia or acute adrenal issues, where blood glucose or cortisol levels drop. They do not correspond with thyroid hormone imbalances or elevated TSH.

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Correct Answer is A

Explanation

A. Notify the rapid response team due to the client’s clinical signs of a tension pneumothorax: The client presents with acute right-sided chest pain, dyspnea, hypotension, unilateral decreased breath sounds, hyperresonance, and agitation—classic signs of a tension pneumothorax, a life-threatening emergency requiring immediate intervention. Rapid response activation ensures rapid access to advanced airway and chest decompression support.
B. Reassure the client and administer prescribed analgesics for pain relief: The pain is a symptom of a serious underlying condition—possibly a collapsed lung. Administering pain medication could delay life-saving intervention.
C. Encourage the client to take deep breaths and use incentive spirometry: This intervention is appropriate for postoperative atelectasis, but it is contraindicated in tension pneumothorax. Increasing intrathoracic pressure through deep breaths may worsen the pneumothorax.
D. Elevate the head of the bed and increase oxygen to 4 L/min via nasal cannula: While increasing oxygen and elevating the head can help improve oxygenation, they do not treat the underlying cause. These supportive measures may be used after emergency intervention has been initiated.
E. Document the findings and re-evaluate in 15 minutes: Delaying intervention in this situation is unsafe. A tension pneumothorax can rapidly lead to cardiovascular collapse, so waiting even a few minutes may result in deterioration or death.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

Chest pain: Crushing, retrosternal chest pain is highly suggestive of cardiac ischemia or acute coronary syndrome. It requires immediate evaluation due to the risk of myocardial infarction. The presence of fatigue and weakness adds to the urgency. Chest pain is always prioritized due to its life-threatening potential.
Visual disturbance: Visual changes may indicate hypertension, hyperglycemia, or neurological issues. While concerning, they are typically not immediately life-threatening. These symptoms can be evaluated after cardiac causes are ruled out. They support further systemic investigation.
Fatigue: Fatigue is a nonspecific symptom seen in many chronic conditions like diabetes, anemia, or heart failure. It does not signal an emergency on its own. It may be related to underlying cardiac issues but is not prioritized over chest pain.
Increased urination: Polyuria often indicates uncontrolled blood glucose levels or diabetes. It should prompt further testing but does not require immediate intervention. It is a chronic symptom rather than an acute, life-threatening one.

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A nurse is reviewing laboratory results and notes that a client has an elevated thyroid-stimulating hormone (TSH) level. Which of the following assessment findings would the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is {"dropdown-group-1":"C"}

Explanation

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