In conducting a health history for a client with erythema, the nurse would include which question?
Do you ever use oxygen?
How many pillows do you sleep on?
Do you feel rested after sleeping?
How far can you walk before feeling short of breath?
The Correct Answer is A
Choice A reason: The nurse would include the question of whether the client ever uses oxygen, as this can be related to erythema. Erythema is a condition where the skin becomes red and inflamed due to increased blood flow or irritation. ¹ One possible cause of erythema is oxygen toxicity, which is a condition where the lungs and tissues are damaged by exposure to high levels of oxygen. ² The nurse would ask the client if they ever use oxygen, especially at high concentrations or for long periods of time, as this can increase the risk of oxygen toxicity and erythema.
Choice B reason: The nurse would not include the question of how many pillows the client sleeps on, as this is not related to erythema. The number of pillows the client sleeps on may indicate the presence of other conditions, such as sleep apnea, acid reflux, or heart failure, but not erythema. ³ The nurse would ask the client about their sleeping habits and preferences, but not specifically about the number of pillows they use.
Choice C reason: The nurse would not include the question of whether the client feels rested after sleeping, as this is not related to erythema. The feeling of restfulness after sleeping may indicate the quality and quantity of sleep the client gets, which can affect their overall health and well-being, but not erythema. The nurse would ask the client about their sleep patterns and problems, but not specifically about their feeling of restfulness.
Choice D reason: The nurse would not include the question of how far the client can walk before feeling short of breath, as this is not related to erythema. The distance the client can walk before feeling short of breath may indicate the level of physical activity and fitness the client has, which can affect their cardiovascular and respiratory health, but not erythema. The nurse would ask the client about their exercise habits and limitations, but not specifically about their walking distance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
hoice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.
Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.
Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.
Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Assessing the apical pulse is not enough to determine if the client is safe to receive digoxin. The client's digoxin level is already above the therapeutic range of 0.5 to 2 ng/mL¹² and giving another dose could increase the risk of toxicity and arrhythmias.
Choice B reason: This is incorrect. Administering 0.25 mcg of digoxin and potassium 20 mEq IV is not appropriate for this client. The client does not need more digoxin or potassium, as both could worsen the client's condition. Potassium levels should be monitored closely in clients taking digoxin, as low or high levels can affect the drug's action and toxicity³.
Choice C reason: This is correct. Withholding the medication and notifying the healthcare provider of the digoxin level is the most appropriate action for this client. The client's digoxin level is dangerously high and could cause serious adverse effects such as nausea, vomiting, vision changes, bradycardia, and cardiac arrest³. The healthcare provider may order to stop digoxin temporarily, adjust the dose, or prescribe an antidote such as digoxin immune fab⁴.
Choice D reason: This is incorrect. Administering the digoxin with a potassium supplement is not advisable for this client. The client's digoxin level is already too high and adding potassium could increase the risk of hyperkalemia, which can impair the heart's electrical activity and lead to cardiac arrest³. Potassium supplements should only be given to clients with digoxin-induced hypokalemia, and only under the supervision of the healthcare provider³..
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