The nurse is completing an assessment of a 42-year-old female with suspected Graves' disease.
The nurse would assess the client for:
Tachycardia.
Cold, clammy skin.
Fatigue.
Weight gain.
The Correct Answer is A
Choice A rationale
Graves' disease is an autoimmune disorder causing hyperthyroidism, characterized by excessive production of thyroid hormones (T3 and T4). These hormones increase the body's metabolic rate, leading to heightened sympathetic nervous system activity, which manifests as an increased heart rate, resulting in tachycardia.
Choice B rationale
Hyperthyroidism, as seen in Graves' disease, accelerates metabolic processes, leading to increased heat production. This typically results in warm, moist skin due to peripheral vasodilation and increased perspiration, rather than cold, clammy skin, which is more characteristic of hypothyroidism or sympathetic activation from shock.
Choice C rationale
Despite an increased metabolic rate, fatigue is a common symptom in Graves' disease. This paradox occurs because the accelerated metabolism and heightened sympathetic stimulation can lead to muscle weakness, sleep disturbances, and overall depletion of energy reserves, resulting in profound tiredness.
Choice D rationale
Hyperthyroidism significantly increases basal metabolic rate, leading to increased caloric expenditure even at rest. This heightened metabolism typically results in weight loss despite an increased appetite, as the body is burning more calories than it consumes. Weight gain is characteristic of hypothyroidism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The copper intrauterine device (IUD) is a highly effective, long-acting reversible contraceptive option that does not contain hormones. It works by releasing copper ions, which create an inflammatory reaction in the uterus, toxic to sperm and eggs, thus preventing fertilization and implantation. Its mechanism is entirely non-hormonal, meeting the client's request.
Choice B rationale
A cervical ring, often referring to a vaginal ring like the NuvaRing, releases hormones (estrogen and progestin) to prevent ovulation. This contradicts the client's request for a hormone-free method of contraception. Hormonal methods work by altering the menstrual cycle and preventing the release of an egg.
Choice C rationale
A cervical cap is a barrier method that requires the use of spermicide to be effective. While it is hormone-free, it is not considered "easy to use" as it requires precise placement over the cervix before each act of intercourse and removal afterward, often necessitating practice for proper insertion and fit.
Choice D rationale
A diaphragm is a barrier method that, similar to a cervical cap, requires the use of spermicide for efficacy. It must be inserted before intercourse and left in place for several hours afterward. This method, while hormone-free, is not considered "easy to use" due to the dexterity and understanding required for proper placement and removal.
Correct Answer is ["79.4"]
Explanation
Step 1 is to convert kilograms to pounds using the conversion factor 1 kg = 2.20462 pounds. 36 kg × 2.20462 pounds/kg = 79.36632 pounds.
Step 2 is to round to the tenth place. The child's weight is 79.4 pounds.
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