Nokea
The nurse is assessing a client with hypothyroidism. Which of the following assessment findings would be expected?
- A. Decreased libido
- B. Bradycardia
- C. Heat intolerance
- D. Fatigue
- E. Constipation
Correct Answer: A, B, D, E
Rationale: Hypothyroidism slows metabolism, leading to decreased libido, bradycardia, fatigue, and constipation. Heat intolerance is associated with hyperthyroidism, not hypothyroidism.
You may also like to solve these questions
The following scenario applies to the next 1 items
The nurse in the medical-surgical unit is caring for a 59-year-old female
Item 1 of 1
Nurses' Notes
0845: Morning capillary blood glucose obtained of 189 mg/dL (10.4 mmol/L). 4 units of lispro insulin administered per sliding scale. Vancomycin infusion started at this time in left peripheral vascular access device that was patent with positive blood return. Call bell placed within reach.
0950: The client alerted RN that they 'didn't feel good.' The client appeared pale, diaphoretic, and lethargic. The client's words became slurred, and she was disoriented, asking, "where am I?" 'The client's breakfast tray appeared untouched. The client's capillary blood glucose was obtained at 41 mg/dL (2.2 mmol/L). Glasgow coma scale: 13. Vital signs: T 98° F (36.7° C), P 108, RR 22, BP 150/86, pulse oximetry reading 95%. A rapid response was called because of the client's condition change.
1000: Rapid response team arrived at the bedside. Report was given to the rapid response nurse.
Medical History
• Diabetes mellitus, type I
• Hyperlipidemia
• Pericarditis
• Asthma
Orders
0700:
• Admit to medical/surgical for cellulitis
• vancomycin 1 g, IV, every 12 hours
• Resume all home medications
• Insulin lispro, sliding scale, before meals
• Consistent carbohydrate diet
• Daily labs: complete blood count and comprehensive metabolic panel
The rapid response nurse receives report from the primary nurse and reviews the medical record. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
- A. Keep the client NPO until mental status improves, Administer glucagon 1 mg intramuscular (IM), Have the client drink 8 ounces (240 mL) of skim milk, Stop the vancomycin infusion.
- B. Creatinine, Glasgow coma scale, Capillary blood glucose, Urinary ketones.
- C. Cerebrovascular accident, Diabetic ketoacidosis (DKA), Hypoglycemia, Vancoymycin infusion reaction.
Correct Answer: C, B, C, B
Rationale: Low glucose (41 mg/dL), pallor, and disorientation indicate hypoglycemia. Administer glucagon for rapid correction, monitor glucose and Glasgow coma scale to assess recovery.
The nurse is caring for a client immediately following transsphenoidal hypophysectomy. It would be essential for the nurse to obtain a prescription for which medication?
- A. Ondansetron
- B. Methimazole
- C. Omeprazole
- D. Methylphenidate
Correct Answer: A
Rationale: Transsphenoidal hypophysectomy often causes nausea from surgical manipulation near the pituitary. Ondansetron controls postoperative nausea. Methimazole is for hyperthyroidism, omeprazole for gastric issues, and methylphenidate for attention disorders.
The nurse is assessing a client with diabetes mellitus type 2. Which of the following findings would be consistent with a diagnosis of diabetes mellitus type 2?
- A. Fasting blood glucose level 110 mg/dL (6.1 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L]
- B. Hemoglobin A1c (HbA1c) level 7.5% [ < 5.7%]
- C. Elevated Serum Insulin Levels
- D. Presence of ketones in the urine
Correct Answer: B
Rationale: HbA1c of 7.5% indicates poor long-term glucose control, consistent with type 2 diabetes (diagnosis: ≥6.5%). Fasting glucose at 110 mg/dL is borderline, elevated insulin reflects resistance, and ketones are more typical of type 1 or DKA.
The following scenario applies to the next 1 items
The emergency department (ED) nurse cares for a 49-year-old male
Item 1 of 1
Nurses' Notes
0914 - Client presents to the ED with his wife reporting headaches, palpitations, sweating, and an occasional tremor in his upper extremities. The client states that these are 'episodes' and usually occur after the client engages in strenuous activity or is under stress. The onset of these symptoms was months ago, and the client could not identify a concrete time frame. The client says he has increased his alcohol consumption from two standard glasses of wine daily to three because of the 'stress at work.' He often wakes up with an occasional headache. He says that the episodes have been occurring more often and that the headaches are frustrating because they do not abate with over-the-counter medications such as acetaminophen. He states that he doesn't have any other symptoms, except he has been drinking more water lately, but attributes that to his work outside setting up a garden. He reports a weight loss of 2 kilograms (4.4 pounds) over the past month. His current body mass index is 23. His medical history includes iron deficiency anemia, herpes simplex virus, and irritable bowel syndrome. His medications include docusate, valacyclovir, and iron sucrose. He reports that his mother and father had a stroke because of high blood pressure, which makes him quite concerned. On assessment, the client is alert and fully oriented. Affect is cooperative. The peripheral pulses are +2. Lung sounds are diminished bilaterally. Bowel sounds were present in all four quadrants. He says he has a headache but cannot provide a numerical rating score stating 'it just hurts.' Vital signs: T 97.5° F (36.4° C), P 110, RR 18, BP 161/80, pulse oximetry reading 96% on room air.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress
- A. Obtain an order for a hemoglobin A1C, Obtain an order for a 24-hour urine collection, Request a prescription for a benzodiazepine, Request a prescription of an antihypertensive.
- B. peripheral pulses, mental status, capillary blood, glucose blood pressure.
- C. alcohol withdrawal syndrome, essential hypertension, pheochromocytoma, diabetes mellitus, type II
Correct Answer: C, A, D, B
Rationale: Pheochromocytoma causes headaches, palpitations, and hypertension from catecholamine excess. Order a 24-hour urine collection for catecholamines, request antihypertensives, and monitor BP and mental status for progress.
The nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate follow-up?
- A. Disorientation
- B. High urine specific gravity
- C. Oliguria
- D. Increased thirst
Correct Answer: A
Rationale: SIADH causes water retention and hyponatremia, which can lead to disorientation—a neurological symptom requiring urgent follow-up to prevent seizures or coma. Other findings are expected.