A nurse is caring for a client who reports increased anxiety, nervousness, heat intolerance, and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH), elevated thyroxine (T4), and elevated triiodothyronine (T3). Which of the following vital sign abnormalities does the nurse anticipate?
Decreased body temperature
Tachycardia
Hypotension
Slow respiratory rate
The Correct Answer is B
Choice A reason: Decreased Body Temperature
Decreased body temperature is not typically associated with hyperthyroidism. In fact, hyperthyroidism often causes an increase in body temperature due to the accelerated metabolic rate. Patients with hyperthyroidism may experience heat intolerance and excessive sweating, but not a decrease in body temperature.
Choice B reason: Tachycardia
Tachycardia, or an abnormally fast heart rate, is a common symptom of hyperthyroidism. The elevated levels of thyroid hormones (T4 and T3) increase the body’s metabolism, leading to an increased heart rate. This can result in palpitations and a feeling of a racing heart, which are characteristic signs of hyperthyroidism. Therefore, tachycardia is the most likely vital sign abnormality in this scenario.
Choice C reason: Hypotension
Hypotension, or low blood pressure, is not typically associated with hyperthyroidism. Instead, hyperthyroidism can sometimes cause an increase in blood pressure due to the heightened metabolic activity and increased cardiac output4. Therefore, hypotension is not a characteristic finding in patients with elevated thyroid hormone levels.
Choice D reason: Slow Respiratory Rate
A slow respiratory rate is not commonly seen in hyperthyroidism. The condition usually leads to an increased respiratory rate due to the body’s heightened metabolic demands. Patients with hyperthyroidism may experience shortness of breath and rapid breathing, but not a slow respiratory rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Coronary arteries do not become more elastic with age. Instead, they tend to become less elastic due to the buildup of plaque, a condition known as atherosclerosis. This buildup narrows the arteries and restricts blood flow, which can lead to coronary artery disease (CAD). The heart not receiving enough oxygen is a result of this narrowing, not increased elasticity.
Choice B Reason:
Coronary arteries decrease in diameter due to the buildup of plaque, which consists of fats, cholesterol, and other substances. This narrowing restricts the flow of blood, oxygen, and nutrients to the heart muscle, leading to symptoms such as chest pain (angina) and shortness of breath. This is the primary mechanism behind coronary artery disease.
Choice C Reason:
This choice is essentially a repetition of Choice B and is correct for the same reasons. The narrowing of the coronary arteries due to plaque buildup leads to insufficient blood flow, causing the heart muscle to receive less oxygen and nutrients.
Choice D Reason:
Manifestations of coronary artery disease are not due to the dilation of coronary arteries. Instead, they are due to the narrowing of these arteries. Increased blood flow and pressure are not typical causes of CAD symptoms. The primary issue is the restricted blood flow due to narrowed arteries.
Choice E Reason:
While it is true that the heart and coronary arteries can weaken over time, leading to poor perfusion and angina, this statement does not accurately describe the primary mechanism of coronary artery disease. The main issue in CAD is the narrowing of the arteries due to plaque buildup, which restricts blood flow to the heart muscle.
Correct Answer is A
Explanation
Choice A: Fasting blood glucose of 140 mg/dL
A fasting blood glucose level of 140 mg/dL is above the normal range (70-99 mg/dL) but may indicate some improvement in beta cell function if it was previously higher. In type 2 diabetes, beta cells in the pancreas are responsible for producing insulin. When beta cells start to restore their function, they can produce more insulin, which helps lower blood glucose levels. However, a fasting blood glucose level of 140 mg/dL still indicates that the client has diabetes and needs to continue managing their condition.
Choice B: Client reports smoking cessation
Smoking cessation is a positive health behavior and can improve overall health, including cardiovascular health, which is often compromised in individuals with diabetes. However, it does not directly indicate the restoration of beta cell function. Beta cell function is specifically related to the pancreas’s ability to produce insulin, and smoking cessation, while beneficial, does not directly impact this.
Choice C: Weight gain of 5 lb
Weight gain can have various implications for a person with type 2 diabetes. While modest weight gain might indicate improved nutritional status or muscle mass, it does not directly indicate the restoration of beta cell function. In fact, weight gain can sometimes worsen insulin resistance, making it harder for beta cells to function effectively.
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