a client with hypothyroidism is experiencing severe lethargy and cold intolerance what action should the nurse take
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Nursing Elites

HESI RN

HESI RN Exit Exam 2024 Capstone

1. A client with hypothyroidism is experiencing severe lethargy and cold intolerance. What action should the nurse take?

Correct answer: A

Rationale: The correct answer is to increase the dose of levothyroxine. In hypothyroidism, the body does not produce enough thyroid hormone, leading to symptoms like lethargy and cold intolerance. Increasing the dose of levothyroxine, which is a synthetic thyroid hormone replacement, helps correct the deficiency and alleviates the symptoms. Choice B, administering antipyretic medication, is incorrect as antipyretics are used to reduce fever, not treat hypothyroidism symptoms. Choice C, providing a warm blanket and increasing room temperature, may provide temporary comfort but does not address the underlying hormonal deficiency. Choice D, increasing fluid intake, is important for overall health but does not directly address the symptoms of hypothyroidism.

2. A client with cirrhosis is prescribed spironolactone to manage ascites. Which serum laboratory value is most important for the nurse to monitor?

Correct answer: D

Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.

3. A client is diagnosed with chronic renal failure, and the nurse is teaching dietary modifications. What should be limited in this client's diet?

Correct answer: C

Rationale: In chronic renal failure, proteins should be limited in the diet. When the kidneys are not functioning well, the buildup of protein byproducts can put additional stress on them. Limiting protein intake can help reduce the burden on the kidneys. Carbohydrates and fats do not need to be restricted in the same way as proteins. Vitamins are essential nutrients that should not be limited in the diet unless specified by a healthcare provider for a specific reason.

4. A client with atrial fibrillation is prescribed warfarin. What is the most important instruction the nurse should give?

Correct answer: D

Rationale: The correct answer is D. Clients taking warfarin should avoid alcohol and over-the-counter medications without consulting their healthcare provider, as these can interact with warfarin and increase the risk of bleeding. Aspirin, in particular, can exacerbate this risk. Choice A is incorrect because taking warfarin with aspirin can increase the risk of bleeding. Choice B is incorrect as while green leafy vegetables contain vitamin K which can interact with warfarin, it is more important to maintain a consistent intake rather than increase it. Choice C is incorrect because foods high in potassium do not directly impact the bleeding risk associated with warfarin.

5. While palpating the gallbladder of a mildly obese client, what finding does the nurse expect if the gallbladder is inflamed?

Correct answer: A

Rationale: Correct. If the gallbladder is inflamed, the nurse would expect to find severe tenderness and guarding, which are typical signs of acute cholecystitis. This indicates an inflammatory process in the gallbladder. Choices B, C, and D are incorrect because slight discomfort, a sensation of fullness, or no symptoms unless extremely inflamed are not typical findings associated with gallbladder inflammation.

Similar Questions

Prior to administering warfarin to a client with a history of atrial fibrillation, what lab result should the nurse review?
A client who has been prescribed multiple antihypertensive medications experiences syncope and has a blood pressure of 70/40. What is the rationale for the nurse to hold the next scheduled antihypertensive dose?
A client is admitted to the hospital with a diagnosis of septic shock. Which assessment finding indicates that the client's condition is deteriorating?
The nurse is caring for a client with a suspected myocardial infarction (MI). Which laboratory test result is most indicative of a recent MI?
A client in heart failure (HF) presents with weakness and poor urine output. Which assessment finding requires immediate action?

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