During the nursing assessment of a patient with Graves' disease. The nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?

“Do you ever have any chest pain?'

“Have you noticed any recent decrease in your appetite?”

“Do you have any problem with frequent constipation?”

Answer and Explanation

The Correct Answer is A

The patient's bounding, rapid pulse and systolic hypertension may indicate cardiovascular complications associated with Graves' disease, such as tachycardia, atrial fibrillation, or congestive heart failure, which can cause chest pain. It is important for the nurse to assess for any symptoms of cardiovascular distress and report any abnormal findings to the healthcare provider for prompt intervention. Questions about appetite and constipation may be relevant to the patient's overall health status, but they are not the most important concern in this situation.

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Correct Answer is C

Explanation

Type 2 diabetes mellitus is a metabolic disorder characterized by high blood sugar levels resulting from decreased insulin secretion and/or increased insulin resistance. In type 2 diabetes, the body's cells become resistant to insulin, which is a hormone that helps regulate blood sugar levels by allowing glucose to enter cells for energy. As a result, the pancreas produces more insulin to compensate for the increased demand, but over time, the pancreas may not be able to keep up, and blood sugar levels rise.

Unlike type 1 diabetes, which is an autoimmune disorder in which the body's immune system destroys the insulin-producing cells in the pancreas, people with type 2 diabetes still produce insulin, but their body is not able to use it eﬀectively. Therefore, type 2 diabetes can be managed through lifestyle changes, such as diet and exercise, and/or medication, such as oral hypoglycemic agents or insulin therapy.

A. Withhold the medication. B. Administer a hypertonic solution. C. Repeat the potassium level. D. Monitor for paresthesia.

Correct Answer is C

Explanation

Before administering any medication, the nurse should confirm the potassium level to ensure that it is still elevated and needs to be treated. Potassium levels can ﬂuctuate, so repeating the test will ensure that the client receives the appropriate treatment.

Options (a) Withhold the medication and (b) Administering a hypertonic solution may be appropriate interventions depending on the client's condition, but confirming the potassium level is the first step.

Option (d) Monitoring for paresthesia is important but not the first action that the nurse should take.

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During the nursing assessment of a patient with Graves' disease. The nurse notes a bounding, rapid pulse and systolic hypertension. Based on these assessment data, which question is important for the nurse to ask the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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