While assessing a client with Graves' disease, the nurse notes that the client's temperature has risen 1° F. Which action should the nurse take first?

Turn the lights down and shut the client's door.

Call for an immediate electrocardiogram (ECG)

Administer a dose of acetaminophen

Calculate the client's apical-radial pulse deficit

Answer and Explanation

The Correct Answer is A

A. Turn the lights down and shut the client's door: Increased body temperature can be an early sign of thyroid storm. Decreasing environmental stimuli (such as light and noise) helps lower stress on the body and may prevent exacerbating the symptoms.

B. Call for an immediate electrocardiogram (ECG): While thyroid storm can cause tachycardia and arrhythmias, an elevated temperature by 1° F alone does not warrant an ECG. The priority is to manage the potential triggers for the rise in temperature first.

C. Administer a dose of acetaminophen: A mild temperature increase in Graves' disease could indicate the beginning of thyroid storm, which requires more immediate interventions like cooling measures and possibly antithyroid medications.

D. Calculate the client's apical-radial pulse deficit: Monitoring for a pulse deficit could be important if the client is experiencing arrhythmias or tachycardia, but the priority is to address the rising temperature and environmental factors, as these can escalate into a thyroid storm.

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Correct Answer is B

Explanation

A. Use sliding scale insulin to manage hypoglycemia: Sliding scale insulin is used to manage hyperglycemia, not hypoglycemia. Sick day management focuses on maintaining stable blood glucose levels, not using sliding scale insulin for hypoglycemia.

B. Continue taking the scheduled insulin or oral hypoglycemic agent: During illness, it is essential for clients with diabetes to continue their medication as prescribed. This helps prevent both hyperglycemia and ketosis, which can occur due to illness-induced stress.

C. Increase intake of carbohydrates for the duration of the illness: It is not necessary to increase carbohydrate intake unless the client is unable to eat enough food. It’s more important to maintain hydration and monitor blood glucose levels, adjusting insulin doses as needed.

D. Report blood glucose lower than 100 mg/dL to the health care provider: Blood glucose levels below 100 mg/dL are generally considered within normal range. During illness, clients may experience higher blood glucose levels, which are more concerning.

A. Full therapeutic effect may take 1 to 3 weeks. B. Full therapeutic effect may take up to 4 months C. Diarrhea as an early side effect diminishes with time. D. Weight gain or edema formation is greatest in the first month.

Correct Answer is A

Explanation

A. Full therapeutic effect may take 1 to 3 weeks: Levothyroxine (Synthroid) typically starts to show effects within 1 to 3 weeks, but full therapeutic effects may take several weeks to months for symptoms like fatigue and depression to improve.

B. Full therapeutic effect may take up to 4 months: Levothyroxine typically shows initial improvement within 1 to 3 weeks, not 4 months. Full stabilization can take a few months, but this is too long for initial effects.

C. Diarrhea as an early side effect diminishes with time: Levothyroxine does not typically cause diarrhea. Constipation is more common in hypothyroidism, and any gastrointestinal issues should be reported to the provider.

D. Weight gain or edema formation is greatest in the first month: Levothyroxine helps reverse weight gain and edema caused by hypothyroidism. Weight gain is not a side effect of the medication.

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While assessing a client with Graves' disease, the nurse notes that the client's temperature has risen 1° F. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should instruct clients with diabetes about "sick day management" of their disease by emphasizing which action?

Correct Answer is B

Explanation

A client who exhibits fatigue, lack of energy, constipation, and depression is diagnosed with hypothyroidism. The physician prescribes levothyroxine (Synthroid). To increase the likelihood of medication compliance in the early course of treatment, the nurse plans to alert the client that:

Correct Answer is A

Explanation

The human insulin whose onset of action occurs within ________ minutes is Humalog (Lispro).

The nurse is reviewing the patient's prescribed insulin regimen. The nurse notes that the physician has ordered a long-lasting insulin. Which medication will best meet this criteria?

A client newly diagnosed with type 2 diabetes mellitus has a nursing diagnosis of Knowledge deficit: diabetes, medical regimen, diet, exercise, and self-care management skills. Which nursing goal is appropriate for this client?

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The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction?

The nurse is teaching a client who has been prescribed propylthiouracil (PTU) for hyperthyroidism. Which statement by the client indicates an understanding of the teaching? (Select 3 options)

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