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: Evaluating for evidence of incontinence is important for understanding the full scope of the seizure's impact on the client. However, it is not the first priority immediately after a seizure. Ensuring the client's airway and breathing status takes precedence.

Choice B reason: Observing for lacerations to the tongue is relevant as it can indicate the severity of the seizure and the potential for airway obstruction. However, the most critical intervention immediately after the seizure is to assess the client's breathing and ensure they are not experiencing prolonged apnoea.

Choice C reason: Documenting the details of the seizure activity is necessary for medical records and future treatment planning. While it is important, it is not the immediate priority. The nurse must first ensure the client's safety and physiological stability.

Choice D reason: Observing for prolonged periods of apnoea is the most urgent intervention. Apnoea, or a pause in breathing, can lead to hypoxia and other serious complications if not addressed immediately. Ensuring that the client is breathing properly is the top priority after a seizure.

A. Cold intolerance. B. Weight gain. C. Hypoventilation. D. Lethargy.

Correct Answer is C

Explanation

Choice A reason: Cold intolerance is a common symptom of hypothyroidism due to the reduced metabolic rate. While it is important to address this symptom, it does not require immediate intervention compared to respiratory issues.

Choice B reason: Weight gain is also a common symptom of hypothyroidism because of the decreased metabolism. It is significant but not immediately life-threatening, so it does not take priority over more urgent conditions.

Choice C reason: Hypoventilation is the most critical finding because it indicates respiratory depression. This can lead to severe hypoxia and carbon dioxide retention, potentially causing life-threatening complications. Immediate intervention is required to support the client's breathing and prevent respiratory failure.

Choice D reason: Lethargy is a common symptom of hypothyroidism due to the overall slowing of the body's functions. While concerning, it is not as immediately dangerous as hypoventilation, which directly affects the client's ability to breathe effectively.

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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

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Correct Answer is C

Explanation

A client with peptic ulcer disease (PUD) is admitted to the medical unit. Which assessment finding requires the most immediate intervention by the nurse?

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