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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Crackles or coarse rales are typically associated with fluid in the airways, such as in cases of congestive heart failure or pneumonia, but they do not directly indicate a pleural effusion.

Choice B reason: A pleural friction rub is associated with pleuritis, where the inflamed pleurae rub against each other. It does not indicate decreased air flow in a specific lobe.

Choice C reason: Low pitched, sonorous rhonchi are related to secretions in the larger airways and are not specific to a pleural effusion or decreased air flow in one lobe.

Choice D reason: Diminished breath sounds in the left upper lobe are consistent with a pleural effusion, as the fluid can reduce air flow and sound transmission in that area. This finding directly correlates with the x-ray results showing decreased air flow in the entire left upper lobe.

A. Tachycardia. B. Edem of the ankles. C. Dyspneal. D. Unilateral diminished breath sounds.

Correct Answer is C

Explanation

Choice A reason: Tachycardia, or a rapid heart rate, can be a symptom associated with COPD, especially during exacerbations or due to medication effects. However, it is not the primary symptom used to evaluate the effectiveness of COPD treatment.

Choice B reason: Edem of the ankles can occur in COPD patients due to right-sided heart failure (cur pulmonale) associated with chronic lung disease. While it is an important symptom to monitor, it is not the primary indicator of COPD treatment effectiveness.

Choice C reason: Dyspneal, or difficulty breathing, is the most significant and primary symptom of COPD. The primary goal of COPD treatment is to improve the client's breathing and reduce dyspneal. Assessing the client's level of breathlessness provides direct insight into how well the treatment is managing the condition.

Choice D reason: Unilateral diminished breath sounds can indicate localized issues such as pneumothorax or pleural effusion rather than the overall effectiveness of COPD treatment. Bilateral lung sounds and general respiratory status are more relevant to evaluating COPD management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The chest x-ray for a client who is admitted for pneumonia shows a pleural effusion with decreased air flow in the entire left upper lobe. After auscultating the left upper lobe, which breath sounds documented by the nurse verify the x-ray findings?

Correct Answer is D

Explanation

During a home visit, the nurse should evaluate the effectiveness of a client's treatment for chronic obstructive pulmonary disease (COPD) by assessing for which primary symptom?

Correct Answer is C

Explanation

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