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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["-2"]

Explanation

Step 1 is to calculate the change in blood pressure. Change in systolic blood pressure = 148 mm Hg - 130 mm Hg = 18 mm Hg. Change in diastolic blood pressure = 88 mm Hg - 80 mm Hg = 8 mm Hg.

Step 2 is to calculate the change in weight. Change in weight = 44.5 kg - 42.2 kg = 2.3 kg.

Step 3 is to calculate the change in pulse oximetry. Change in pulse oximetry = 98% - 100% = -2%.

A. Hearing loss. B. Speech problems. C. Frequent seizures. D. Difficulty walking. E. Cognitive delays.

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

Explanation

Choice A rationale

While hearing loss can occur in some individuals with spina bifida due to associated anomalies or complications like meningitis, it is not as universally expected as other neurological impairments. The primary impact of hydrocephalus and neurological damage often manifests in areas directly related to brain development and function, making hearing loss a less common direct consequence.

Choice B rationale

Neurological damage associated with hydrocephalus and spina bifida frequently affects brain regions responsible for speech production and language processing. This can lead to various speech problems, including dysarthria or apraxia of speech, due to impaired motor control or cognitive deficits impacting linguistic expression and comprehension.

Choice C rationale

Frequent seizures are a potential complication of hydrocephalus and neurological damage due to abnormal electrical activity in the brain caused by structural anomalies or increased intracranial pressure. However, while possible, they are not as universally present in all cases as other common motor and cognitive impairments, making them a less frequent expectation.

Choice D rationale

Spina bifida often involves malformations of the spinal cord, directly impacting nerve function to the lower extremities. Hydrocephalus, by causing increased intracranial pressure and brain damage, can further impair motor control pathways. This combination frequently leads to motor deficits, resulting in varying degrees of difficulty walking or complete paralysis.

Choice E rationale

Hydrocephalus, especially when associated with neurological damage, can significantly impair cognitive development due to increased intracranial pressure and damage to brain tissue. This can manifest as delays in various cognitive domains, including learning, memory, problem-solving, and executive functions, impacting overall intellectual functioning.

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The nurse is completing an assessment of a 42-year-old female with suspected Graves' disease. The nurse would assess the client for:

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["-2"]

Explanation

A nurse is caring for a child with spina bifida and an associated complication of hydrocephalus with neurological damage. Which of the following conditions should the nurse expect to accommodate during care?

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

Explanation

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The nurse is completing an assessment of a 42-year-old female with suspected Graves' disease.
The nurse would assess the client for: