The nurse is interviewing a client with possible Graves' disease. Which response would the nurse expect when asking the client about her comfort in cold weather?

"I always need to have a sweater or jacket on."

"I am always warm and sometimes even hot during cold weather."

"I seem to have episodes of hot and cold without regard to what I am wearing."

"My fingers are sometimes cold during the cooler weather."

Answer and Explanation

The Correct Answer is B

Choice A reason: Needing a sweater or jacket is not typical for Graves' disease, which often causes intolerance to heat rather than cold.

Choice B reason: This response is typical for Graves' disease, as hyperthyroidism can increase metabolism, leading to feeling warm or hot even in cold weather.

Choice C reason: While temperature dysregulation can occur, the specific symptom of feeling warm in cold weather is more directly associated with Graves' disease.

Choice D reason: Cold fingers can be a symptom of many conditions, but it is not specifically indicative of Graves' disease.

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Correct Answer is B

Explanation

Choice A reason: Prolonged vomiting typically leads to metabolic alkalosis due to the loss of gastric acid, which is not consistent with the ABG results showing acidosis.

Choice B reason: COPD can lead to respiratory acidosis, as indicated by the elevated PaCO2 and low pH in the ABG results, making it a likely contributor to these findings.

Choice C reason: Chronic renal failure can lead to metabolic acidosis, but the HCO3 level is within the normal range, which does not support this as the primary condition.

Choice D reason: Anxiety and hyperventilation usually result in respiratory alkalosis due to the excessive exhalation of CO2, which is the opposite of what the ABG results show.

A. Serum lactate level 3.9 mmol/L (normal range: 0.5-2 mmol/L) B. Vital signs: Temperature 100°F, Heart rate 88 bpm, Respiratory rate 22 breaths/min, Blood pressure 124/72 mmHg C. Pulse oximetry 96% on oxygen at 2 L/min via nasal cannula D. Breath sounds with rhonchi bilaterally

Correct Answer is A

Explanation

Choice A reason: The serum lactate level of 3.9 mmol/L is significantly higher than the normal range of 0.5-2 mmol/L. This is a critical value to report as it indicates a high likelihood of sepsis, which is a life-threatening condition requiring immediate intervention. Elevated lactate levels suggest that the tissues are not adequately oxygenated, a state known as tissue hypoxia, which is a hallmark of sepsis.

Choice B reason: While the vital signs show a slight fever (100°F), the heart rate, respiratory rate, and blood pressure are within normal limits for an adult and do not indicate an immediate life-threatening condition.

Choice C reason: A pulse oximetry reading of 96% on supplemental oxygen is within the acceptable range, indicating adequate oxygen saturation and not a direct sign of sepsis.

Choice D reason: The presence of rhonchi bilaterally suggests airway obstruction due to mucus, which can be associated with pneumonia. However, this finding alone does not carry the same immediate risk of morbidity and mortality as an elevated lactate level indicative of sepsis.

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The nurse is interviewing a client with possible Graves' disease. Which response would the nurse expect when asking the client about her comfort in cold weather?

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Naxlex Comprehensive Predictor Exams

A client's arterial blood gas (ABG) reads: pH 7.18, PaCO2 54 mm Hg, HCO3 26 mEq/L. What condition does the nurse recognize may contribute to the development of this result? Normal values: pH: 7.35-7.45, PaCO2: 35-45 mm Hg, HCO3: 22-26 mEq/L

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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