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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A soft diet with thin liquids may be recommended for patients with Parkinson's disease who have difficulty swallowing (dysphagia), but it is not the most appropriate intervention for all patients. Dysphagia is common in Parkinson's disease due to impaired muscle movement, and a soft diet can help prevent choking and aspiration.
Choice B reason: Assessing for orthostatic hypotension is crucial in the care of patients with Parkinson's disease. Orthostatic hypotension is a common non-motor symptom where there is a significant drop in blood pressure upon standing. Normal blood pressure should not drop more than 20 mm Hg systolic or 10 mm Hg diastolic within 2 to 5 minutes of standing². This condition can increase the risk of falls, which is a significant concern in this population.
Choice C reason: Exophthalmos, the bulging of the eyes, is not associated with Parkinson's disease. It is typically related to thyroid eye disease, such as Graves' disease, and would not be a relevant assessment for a Parkinson's patient unless there is a known co-existing thyroid condition.
Choice D reason: Limiting fluids to prevent urinary incontinence is not an appropriate intervention for Parkinson's disease. Adequate hydration is essential, and urinary incontinence should be managed with other strategies, such as bladder training, scheduled toileting, and possibly medication, depending on the cause.
Correct Answer is C
Explanation
Choice A reason: Administering oxygen via mask is appropriate for a client with sepsis who may have compromised oxygenation.
Choice B reason: Obtaining a serum lactate level is important in sepsis as it can indicate the severity of the condition and guide treatment.
Choice C reason: An infusion rate of 0.9% Normal Saline at 50 mL/hr may be questioned because clients with sepsis may require more aggressive fluid resuscitation.
Choice D reason: Obtaining blood and urine cultures is essential before starting antibiotics to identify the causative organism in sepsis.
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