The nurse is caring for a client during treatment of myxedema and the client reports experiencing chest pain. Which of the following actions should be a priority for the nurse to take?

Administer prescribed morphine sulphate.

Stop thyroid hormone administration.

Obtain serum cardiac enzymes.

Complete a pain assessment.

Answer and Explanation

The Correct Answer is D

A. While morphine may be indicated for pain management, particularly if the pain is severe, the priority is first to assess the cause of the chest pain. Chest pain in a patient with myxedema could be related to a number of serious conditions, such as a myocardial infarction or worsening cardiovascular issues, so it is important to assess the pain thoroughly before administering any medications.
B. Stopping thyroid hormone administration is not the correct action. Myxedema is a severe form of hypothyroidism, and thyroid hormone therapy is essential in treating this condition. However, if there is a concern about the cause of the chest pain (such as a heart attack), stopping the thyroid hormone might not be appropriate unless directly indicated by a physician.
C. While obtaining cardiac enzymes can be an important diagnostic step if the chest pain is suspected to be related to a cardiac event, the priority at this moment is to assess the pain and clinical presentation more thoroughly. Cardiac enzymes can be checked after a full assessment of the symptoms.
D. The first priority is to complete a comprehensive pain assessment. The nurse should assess the quality, intensity, and duration of the chest pain and ask relevant questions to determine if the pain is cardiac in nature (e.g., tightness, radiating to left arm, sweating) or possibly related to the thyroid condition (e.g., could be related to complications of myxedema, such as hypothyroid-induced cardiac dysfunction). This step is critical to understanding the cause and ensuring appropriate next steps for care.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Place the client in the recovery position if possible. If the client is not actively seizing, placing them in the recovery position (on their side) can help prevent aspiration and allow for better airway management after the seizure ends. However, during the seizure, ensure their safety first.
B. Document the start and stop time of the seizure. It is important to document the timing of the seizure to help assess its duration and determine the appropriate interventions. This also helps guide treatment decisions post-seizure.
C. Hold arms at the client's side to prevent thrashing or injury. The nurse should not restrain the client during a seizure. Trying to hold the client’s arms or restrict their movements can cause injury. The goal is to ensure safety and prevent injury, but not to restrain them.
D. Remove any dangerous objects near the client. Clearing the area of any hard or sharp objects can prevent injury to the client during the seizure.
E. Assist the client to the floor. If the client is standing or sitting during the onset of the seizure, assist them to the floor gently to prevent injury from falling. Ensure that the area is clear of hazards.

A. Gestational diabetes B. Secondary diabetes C. Type 2 diabetes mellitus D. Type 1 diabetes mellitus

Correct Answer is D

Explanation

A. Gestational diabetes occurs during pregnancy and typically resolves after delivery. It does not typically lead to diabetic ketoacidosis (DKA), though women with gestational diabetes are at higher risk for developing type 2 diabetes later in life.
B. Secondary diabetes results from another condition (such as a hormonal disorder or medication use) and is less commonly associated with DKA.
C. While DKA can occur in type 2 diabetes, it is much more common in type 1 diabetes, especially in cases of severe insulin deficiency or missed insulin doses.
D. Diabetic ketoacidosis (DKA) is most commonly associated with type 1 diabetes mellitus. It occurs due to a severe lack of insulin, which leads to hyperglycemia, dehydration, and the production of ketones. DKA is a life-threatening complication often seen in newly diagnosed individuals or those with poor diabetes management.

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The nurse is caring for a client during treatment of myxedema and the client reports experiencing chest pain. Which of the following actions should be a priority for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is having an active seizure. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

The nurse is teaching a client about diabetic ketoacidosis (DKA). Which of the following types of diabetes does the client most likely have?

Correct Answer is D

Explanation

The nurse is teaching a female client about ways to prevent a migraine. Which of the following information should the nurse include in the teaching?.

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The nurse has taught a client with hypothyroidism about thyroid replacement therapy. Which of the following statements by the client would indicate the need for more teaching?

The nurse is teaching a client with hypothyroidism the importance of increasing fluids. The nurse should explain that increasing fluids is important to prevent which of the following problems?

The nurse is caring for a client receiving treatment for myxedema. The nurse should explain that warm blankets are used to warm the client instead of heating pads for which of the following reasons?

The nurse in the emergency department is caring for a client with diabetic ketoacidosis and has the following prescriptions. Which of these prescriptions should the nurse clarify?

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