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The nurse is caring for a client who recently had a dosage increase of prescribed levothyroxine. Which of the assessments following the increase is a priority?
- A. Weight
- B. Heart rate
- C. Activity status
- D. Oral temperature
Correct Answer: B
Rationale: Levothyroxine increases metabolism, and a dosage increase can cause hyperthyroidism symptoms, including tachycardia. Monitoring heart rate is a priority to detect adverse effects like arrhythmias. Weight, activity status, and temperature are relevant but less urgent.
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The following scenario applies to the next 1 items
The home health nurse visits a client with chronic diabetes insipidus
Item 1 of 1
Nurses’ Note
1415 – Home health visit completed because the client was admitted to the hospital twice in the past six weeks for treatment nonadherence related to diabetes insipidus. Extensive teaching provided and reviewed education on prescribed desmopressin intranasal, maintenance of fluids, daily weight, intake and output, and when to seek emergency care.
Which client statements would indicate a correct understanding of the teaching?
- A. I should limit the amount of fluids that I drink after 5:00 PM.
- B. I will need to weigh myself at the same time every day.
- C. I should put both doses of the desmopressin in one nostril.
- D. I need to keep a log of my fluid intake and urine output.
- E. I may need an additional dose if I keep urinating a lot.
- F. If I develop confusion with this medication, I should call 911.
Correct Answer: B, D, F
Rationale: Daily weighing and logging intake/output monitor diabetes insipidus. Confusion may signal hyponatremia, needing emergency care. Fluid limits are incorrect, desmopressin dosing is per nostril, and extra doses require a provider's order.
The nurse caring for a diabetes mellitus client obtained a scheduled capillary blood glucose. The result indicated 40 mg/dL (2.22 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The client reports no symptoms. The initial action of the nurse should be which of the following?
- A. Document the finding in the medical record
- B. Repeat the capillary blood glucose test to validate the result
- C. Administer 15 grams of a quick-acting carbohydrate
- D. Administer 1 mg of glucagon subcutaneously
Correct Answer: B
Rationale: A glucose of 40 mg/dL is critically low, even without symptoms. Repeating the test validates the result, ensuring accuracy before treatment to avoid unnecessary intervention.
The nurse is caring for a client suspected of having an endocrine disorder. Based on the client's laboratory data, the nurse is at the highest risk for which condition? See the exhibit.
- A. syndrome of inappropriate antidiuretic hormone (SIADH)
- B. diabetes insipidus (DI)
- C. cushing's syndrome/disease
- D. adrenal insufficiency
Correct Answer: C
Rationale: Without specific lab data, Cushing's is a common suspect in endocrine disorders with weight gain, hyperglycemia, and hypertension. SIADH, DI, and adrenal insufficiency require specific lab patterns (e.g., sodium, urine output).
The nurse is caring for a client who has acute pancreatitis. Based on the 11:15 AM vital signs, the nurse should prioritize which action? Click to view the exhibit for additional client information.
- A. Obtain a 12-lead electrocardiogram
- B. Assess the client for pain
- C. Apply oxygen via nasal cannula
- D. Infuse 500 ml 0.9% sodium chloride (normal saline) bolus
Correct Answer: B
Rationale: Acute pancreatitis causes severe pain, a hallmark symptom. Without vital signs data, pain assessment is the priority to guide treatment and comfort, preceding ECG, oxygen, or fluids.
The nurse is developing a plan of care for a client with hypothyroidism that is not controlled with medication. The nurse should recommend
- A. applying lotion after a warm bath.
- B. high-fiber snacks.
- C. caffeinated beverages to promote energy.
- D. physical activities with frequent rest breaks.
- E. adding fans to the room to keep it cool.
Correct Answer: A, B, D
Rationale: Hypothyroidism causes dry skin, constipation, and fatigue. Lotion hydrates skin, high-fiber snacks aid bowel movements, and rest breaks accommodate low energy. Caffeine may overstimulate, and fans are unhelpful as clients feel cold, not hot.