The nurse is assessing a patient with a history of Graves' disease. The assessment is in the chart below. Which interventions will the nurse include in the plan of care? (Select All That Apply)

Assessment:

Respiratory Rate: 28 breaths/minute

Heart rate: 145 beats/minute and irregular

Temperature: 102.2°F (39°C)

Blood pressure: 167/80 mmHg

Level of consciousness: Decreased

Apply a hypothermia blanket.

Administer humidified oxygen.

Administer aspirin 325 mg orally.

Administer D5NS intravenous infusion.

Administer propylthiouracil.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Applying a hypothermia blanket is appropriate for managing hyperthermia in a patient with Graves' disease. Elevated temperatures (fever) are common in thyroid storm, a severe complication of Graves' disease. Using a hypothermia blanket helps reduce the body temperature and prevent further complications.

Choice B reason: Administering humidified oxygen is important for supporting respiratory function in a patient with increased respiratory rate and decreased level of consciousness. Humidified oxygen can help alleviate respiratory distress and improve oxygenation.

Choice C reason: Administering aspirin 325 mg orally is not recommended for patients with hyperthyroidism or thyroid storm. Aspirin can increase free thyroid hormone levels by displacing thyroid hormone from its binding proteins, potentially worsening the patient's condition. Acetaminophen is a safer alternative for managing fever in these patients.

Choice D reason: Administering D5NS intravenous infusion is appropriate for managing dehydration and electrolyte imbalances in a patient with thyroid storm. This intervention helps maintain fluid balance and provides dextrose for energy.

Choice E reason: Administering propylthiouracil is a key intervention for managing thyroid storm. Propylthiouracil inhibits thyroid hormone synthesis and peripheral conversion of T4 to T3, helping to reduce thyroid hormone levels and alleviate symptoms.

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Correct Answer is C

Explanation

Choice A reason: Encouraging the patient to rest in bed for most of the day may lead to further deconditioning and muscle weakness. While rest is important, balancing activity and rest is more beneficial for managing fatigue in chronic anemia.

Choice B reason: Administering a high-protein diet including caffeinated beverages to increase energy levels is not recommended. While a high-protein diet can support energy and muscle strength, caffeine may cause jitteriness and disrupt sleep, which can exacerbate fatigue.

Choice C reason: Assisting the patient with ADLs and encouraging frequent rest periods is appropriate for managing fatigue, weakness, and activity intolerance in chronic anemia. This approach helps the patient conserve energy while maintaining some level of activity to prevent deconditioning.

Choice D reason: Providing supplemental oxygen via face mask during vigorous exercises is not appropriate. Patients with chronic anemia should avoid vigorous exercises that could exacerbate fatigue and weakness. The focus should be on moderate, manageable activities with adequate rest.

A. The patient is increasingly drowsy and hard to arouse. B. The patient's feet and hands are covered with red, raised purpura.

Correct Answer is A

Explanation

Choice A reason: The patient being increasingly drowsy and hard to arouse is an urgent finding that should be reported immediately. This condition may indicate intracranial bleeding or other severe complications related to extremely low platelet count (10,000/mm³) in idiopathic thrombocytopenic purpura (ITP). Immediate medical intervention is required to prevent further deterioration.

Choice B reason: Red, raised purpura on the patient's feet and hands is a concerning finding indicative of significant thrombocytopenia, but it is not as immediately life-threatening as decreased consciousness. It should still be monitored and managed, but the priority is the patient's level of consciousness.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient admitted to the hospital with chronic anemia. The patient reports persistent fatigue, weakness, and activity intolerance. Which intervention will the nurse implement for these manifestations?

Correct Answer is C

Explanation

The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP) whose platelet count is 10,000/mm³. What assessment finding will the nurse report to the provider immediately?

Correct Answer is A

Explanation

The nurse is assessing a patient who is diagnosed with inflammatory bowel disease and is requiring inpatient treatment at a hospital. What medication will the nurse provide when caring for this patient?

The nurse is admitting a patient with pulmonary edema resulting from heart failure. Upon assessment, the nurse notes that the patient is hyperventilating. What lab results will the nurse expect to see?

The nurse is in the G unit is assessing a patient after receiving the change of shift SBAR report. What assessment findings will the nurse report immediately to the provider?

The nurse is caring for a patient with hyperosmolar hyperglycemic syndrome. The patient is receiving intravenous fluids of normal saline with 20 mEq of potassium chloride and a continuous insulin infusion. Which finding will indicate to the nurse that the treatment is effective?

The nurse is caring for a patient receiving chemotherapy who is admitted with an absolute neutrophil count (ANC) of 459 cells/ulu. The healthcare provider orders G-CSF (filgrastim). Which action will the nurse take to promote safe and effective use of filgrastim for this patient?

The nurse is caring for a patient newly diagnosed with chronic obstructive pulmonary disease (COPD), who has an order for prednisone orally. When planning medication teaching, the nurse will plan to include which potential side effect of this medication?

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