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 D

Explanation

A blood glucose reading of 48 is considered low and requires immediate intervention to raise the client's blood sugar. Intravenous dextrose solution is the fastest way to raise blood sugar levels in an unconscious client. Glucagon and cortisone can also be used to raise blood sugar levels, but they are not the first-line treatment for hypoglycemia.

Choice A, orange juice, is not appropriate for an unconscious client as they cannot swallow or drink.

A. Increased pulse rate, adventitious breath sounds. B. Increased pulse rate, respirations of 16 breaths/minute. C. Decreased pulse rate, respirations of 20 breaths/minute. D. Decreased pulse rate, abdominal breathing.

Correct Answer is A

Explanation

Increased pulse rate, adventitious breath sounds. Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. It can cause weakness, paralysis, and difficulty breathing. Increased pulse rate and adventitious breath sounds, such as crackles or wheezes, may indicate that the client is experiencing respiratory distress and needs oral suctioning. Increased pulse rate and respirations of 16 breaths/minute, choice B, may indicate anxiety or pain but are not necessarily indicative of the need for oral suctioning.

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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

The nurse is checking the blood glucose of a client and has a reading of 48. The client is not easily awakened and only responds with a groan. What will the nurse administer to raise the blood glucose level?

Correct Answer is D

Explanation

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Correct Answer is A

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?