A nurse is reviewing the medical records of clients on a hospital floor. Which client would the nurse expect is most at risk for hyperthyroidism?

A 25-year-old female who has metabolic syndrome

A 73-year-old male who has an iodine deficiency

A 35-year-old male who has Graves' disease

A 45-year-old female who has a family history of autoimmune disorders

Answer and Explanation

The Correct Answer is C

Choice A reason:
While metabolic syndrome is associated with several health issues, it is not a direct risk factor for hyperthyroidism. Metabolic syndrome typically includes conditions like insulin resistance, hypertension, and dyslipidemia, which are more closely related to diabetes and cardiovascular diseases rather than thyroid function.

Choice B reason:
An iodine deficiency is commonly associated with hypothyroidism, not hyperthyroidism. Iodine is essential for the production of thyroid hormones, and a lack of it can lead to decreased hormone production and an underactive thyroid.

Choice C reason:
Graves' disease is the most common cause of hyperthyroidism. It is an autoimmune disorder where the immune system mistakenly attacks the thyroid gland, causing it to produce too much thyroid hormone. A 35-year-old male with Graves' disease would indeed be at high risk for hyperthyroidism.

Choice D reason:
While a family history of autoimmune disorders can increase the risk of developing autoimmune-related hyperthyroidism, it is not as direct a risk factor as having Graves' disease itself. Autoimmune disorders can have a genetic component, but having a family history does not guarantee the development of hyperthyroidism.

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

Explanation

The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.

Choice A reason:

a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.

Choice B reason:

b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.

Choice C reason:

c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.

Choice D reason:

d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.

Choice E reason:

e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.

A. Inspect the mouth for signs of inhalation injuries. B. Insert an indwelling urinary catheter. C. Draw blood for a complete blood cell (CBC) count. D. Administer intravenous pain medication.

Correct Answer is A

Explanation

Choice A reason:
In the case of burns to the face and chest, assessing for inhalation injuries is critical due to the potential for airway compromise. Inhalation injuries can lead to significant respiratory distress and are considered a high priority in burn care. Inspecting the mouth for soot, burns, or edema can provide immediate information about the potential for respiratory complications, which can be life-threatening.

Choice B reason:
While monitoring urine output is important in burn patients for assessing fluid balance and kidney function, it is not the immediate priority. The insertion of an indwelling urinary catheter can be performed after stabilizing the airway and ensuring the patient is breathing adequately.

Choice C reason:
A CBC count is important for evaluating the patient's overall health status and can indicate the presence of infection or anemia. However, it is not the first action to take in the emergency setting where immediate life-saving interventions are prioritized.

Choice D reason:
Administering intravenous pain medication is important for patient comfort and can facilitate further care, but it is not the first priority. The initial focus should be on life-saving measures such as securing the airway and assessing for inhalation injuries.

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A nurse is reviewing the medical records of clients on a hospital floor. Which client would the nurse expect is most at risk for hyperthyroidism?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)

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

Explanation

Choice A reason:

Choice B reason:

Choice C reason:

Choice D reason:

Choice E reason:

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Correct Answer is A

Explanation

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