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The nurse is caring for a patient with stage IV metastatic breast cancer, who has metastasis to the bone.
During assessment, the patient appears severely weak, fatigued, confused, and continually repeats "I'm so thirsty!” What will the nurse implement in the patient's plan of care?

Notify the provider that the patient is exhibiting signs of hypercalcemia and draw blood to obtain ionized calcium level.

Notify the provider that the patient is exhibiting signs of tumor lysis syndrome and draw blood to obtain uric acid level.

Notify the provider that the patient is exhibiting signs of infection and request an order for blood cultures.

Notify the provider that the patient is exhibiting signs of bleeding and request an order for a packed red blood cell transfusion.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Hypercalcemia is common in patients with bone metastasis. Symptoms include weakness, fatigue, confusion, and excessive thirst. The nurse should notify the provider and draw blood to obtain the ionized calcium level for proper diagnosis and treatment.

Choice B rationale

Tumor lysis syndrome typically occurs in patients with rapidly proliferating tumors undergoing treatment, leading to the release of intracellular contents. Symptoms include hyperuricemia, not excessive thirst. This choice does not match the patient's presentation.

Choice C rationale

While infection can cause weakness and confusion, it does not typically cause extreme thirst. The patient's symptoms are more indicative of hypercalcemia, making this choice less relevant.

Choice D rationale

Bleeding can cause weakness and confusion due to anemia, but it does not cause extreme thirst. The symptoms of the patient are more aligned with hypercalcemia than bleeding.

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Correct Answer is B

Explanation

Choice A rationale

While a reduced-calorie diet may be helpful in some conditions, patients with hyperthyroidism typically require high-calorie diets due to their elevated metabolic rate.

Choice B rationale

Small, frequent meals high in protein and carbohydrates help to meet the increased metabolic demands and prevent muscle wasting in hyperthyroid patients.

Choice C rationale

Large, bland meals are not ideal as patients with hyperthyroidism have high metabolic rates and may require more frequent nutrient intake.

Choice D rationale

While fiber is beneficial for digestive health, it does not specifically address the high metabolic needs of hyperthyroid patients.

A. Administer intravenous fluids with glucose. B. Administer 1000 mg of acetaminophen orally. C. Educate the patient about ordered hydrocortisone. D. Explore options to minimize stress.

Correct Answer is A

Explanation

Choice A rationale

Administering intravenous fluids with glucose is essential for a patient with Addison's disease who has been exposed to stressors like prolonged sun exposure. Patients with Addison's disease may experience an adrenal crisis, characterized by low blood pressure, dehydration, and hypoglycemia. Intravenous fluids with glucose help to rehydrate the patient and restore blood sugar levels, which are critical in preventing shock and other severe complications.

Choice B rationale

Administering 1000 mg of acetaminophen orally is not the priority intervention for this patient. While it may help reduce fever, it does not address the underlying issues of Addison's disease, such as hypoglycemia and dehydration, which are more urgent. The primary concern should be stabilizing the patient's vital signs and electrolyte balance.

Choice C rationale

Educating the patient about ordered hydrocortisone is important for long-term management of Addison's disease, but it is not the immediate priority in an emergency situation. The patient requires prompt medical intervention to address the acute symptoms of adrenal insufficiency, such as lethargy and hypoglycemia.

Choice D rationale

Exploring options to minimize stress is relevant for managing Addison's disease in general, as stress can trigger an adrenal crisis. However, in the emergency department, the nurse's priority should be to stabilize the patient and manage acute symptoms. Stress management can be addressed once the patient's condition is stabilized.

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The nurse is caring for a patient with stage IV metastatic breast cancer, who has metastasis to the bone.During assessment, the patient appears severely weak, fatigued, confused, and continually repeats "I'm so thirsty!” What will the nurse implement in the patient's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning the care of a patient with hyperthyroidism.What should the nurse specify in the patient's meal plan?

Correct Answer is B

Explanation

The nurse is caring for a patient with Addison's disease in the emergency department.The patient states that they were out in the sun gardening all day and is now lethargic, forgetful, and has a temperature of 101.5°F. What intervention will the nurse prioritize when caring for this patient?

Correct Answer is A

Explanation

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The nurse is caring for a patient who was treated for Addisonian crisis.What clinical change indicates to the nurse that the prescribed therapy was effective?

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The nurse is caring for a patient with stage IV metastatic breast cancer, who has metastasis to the bone.
During assessment, the patient appears severely weak, fatigued, confused, and continually repeats "I'm so thirsty!” What will the nurse implement in the patient's plan of care?