The nurse is performing an assessment of the thyroid gland. In order to decrease the risk that the nurse will stimulate the release of large amounts of thyroid hormone, what should the nurse be sure to do?

Palpate gently without repeated attempts.

Not palpate the thyroid and just listen for a bruit.

Palpate firmly in order to feel the thyroid gland.

Continue to palpate the gland until it is felt for enlargement.

Answer and Explanation

The Correct Answer is A

Palpate gently without repeated attempts. Palpating the thyroid gland can stimulate the release of thyroid hormone, which can result in a thyroid storm, a potentially life-threatening condition characterized by a rapid heart rate, fever, and high blood pressure. Therefore, the nurse should be careful not to overstimulate the thyroid gland.

Not palpating the thyroid and just listening for a bruit (B) is not a sufficient assessment of the thyroid gland. Palpating the gland firmly in order to feel it for enlargement (C) can be too stimulating and increase the risk of thyroid hormone release. Continuing to palpate the gland until it is felt for enlargement (D) is not necessary and may result in overstimulation of the gland.

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Correct Answer is A

Explanation

choice A, Obtain a glucometer reading. The immediate action taken by the nurse is to obtain a glucometer reading to determine the client's blood glucose level. The client's symptoms are suggestive of hypoglycemia, a condition that can lead to coma and seizures if left untreated. Administering fruit juice or starting an IV of dextrose without first checking the client's blood glucose level can worsen the condition if the client's blood glucose is high. The physician should be notified if the client's blood glucose level is critically low or high and if the client's condition does not improve after treatment.
B. Administering fruit juice can worsen the condition if the client's blood glucose is high.
C. Starting an IV of dextrose can worsen the condition if the client's blood glucose is high.
D. Calling the physician is not the immediate action, as the client needs urgent treatment.

A. Diarrhea. B. Ringing in the ears. C. Dry eyes. D. Dry hacking cough.

Correct Answer is B

Explanation

Ringing in the ears. Salicylate toxicity or salicylism is a condition that occurs when a client is taking large amounts of salicylates, which can result in symptoms such as tinnitus or ringing in the ears, nausea, vomiting, and diarrhea. Clients should report these symptoms to their healthcare provider immediately to prevent further complications.

Choice A, diarrhea, is not a symptom of salicylate toxicity, but rather a potential side effect of the medication in normal doses.

Choice C, dry eyes, and choice D, dry hacking cough, are not symptoms of salicylate toxicity.

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The nurse is performing an assessment of the thyroid gland. In order to decrease the risk that the nurse will stimulate the release of large amounts of thyroid hormone, what should the nurse be sure to do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

On initial nursing rounds, the diabetic client reports "not feeling well." Later, the nurse finds the client to be diaphoretic and in a stuporous state. What is the immediate action taken by the nurse?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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The nurse is performing an assessment of the thyroid gland. In order to decrease the risk that the nurse will stimulate the release of large amounts of thyroid hormone, what should the nurse be sure to do?

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