The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?
Pace the client's care to provide periods of rest.
Make arrangements for radioactive iodine therapy.
Administer beta-adrenergic blocking agent.
Monitor the client's vital signs frequently.
The Correct Answer is D
Choice A reason: Pacing the client's care to provide periods of rest is important for managing fatigue and preventing overexertion. However, it is not the first action the nurse should take in this situation. Monitoring vital signs is crucial to assess the client's current condition and detect any immediate complications.
Choice B reason: Making arrangements for radioactive iodine therapy is a treatment option for hyperthyroidism. However, this is not the first action the nurse should take. The nurse needs to assess the client's condition and stabilize any immediate issues before considering long-term treatment options.
Choice C reason: Administering a beta-adrenergic blocking agent can help manage symptoms such as a racing heartbeat and nervousness. While this may be part of the treatment plan, it is not the first action the nurse should take. Monitoring vital signs is essential to determine the appropriate interventions.
Choice D reason: Monitoring the client's vital signs frequently is the first action the nurse should take. This helps assess the client's current condition, detect any immediate complications, and guide further interventions. It is crucial to ensure the client's stability before implementing other care measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Denial of urinary frequency, urgency, or dysuria is a good sign of symptom relief but does not directly confirm the success of the lithotripsy in terms of stone removal.
Choice B reason: The presence of stone fragments in the urine after lithotripsy indicates that the procedure successfully broke up the kidney stones, allowing them to be excreted. This is a direct and specific measure of the procedure's effectiveness.
Choice C reason: Pale pink urine with no observable blood clots is a positive sign and suggests that there is no significant bleeding, but it does not directly confirm the removal of the kidney stones.
Choice D reason: Normal serum creatinine and blood urea nitrogen (BUN) levels indicate good kidney function but do not specifically reflect the success of the lithotripsy in breaking up and removing the stones.
Correct Answer is B
Explanation
Choice A reason: Drinking several bottles of carbonated water daily is not a well-established risk factor for renal calculi. While hydration is important in preventing kidney stones, carbonation itself does not significantly increase the risk.
Choice B reason: Eating a vegetarian diet with cheese 2 to 3 times a day can increase the risk for kidney stones, especially if the cheese is high in calcium or oxalates. Dairy products, including cheese, contain calcium, and excessive consumption can contribute to the formation of calcium oxalate stones, which are the most common type of kidney stones.
Choice C reason: Experiencing additional stress since adopting a child is not directly related to the formation of kidney stones. Stress can have various health impacts, but it is not a known primary risk factor for renal calculi.
Choice D reason: Jogging more frequently than the usual daily routine is not associated with an increased risk of kidney stones. Regular physical activity is generally beneficial for overall health and does not contribute to the formation of renal calculi.
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