Med-Surg II HESI Exam - set one questions and answers 100% verified.

Med-Surg II HESI Exam - set one questions and answers 100% verified. The nurse is completing a health assessment of a 42-year-old female with suspected Graves' Disease. The nurse should assess this client for: 1. anorexia 2. tachycardia 3. weight gain 4. cold skin -correct answers. 2. tachycardia Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism. CN: Physiological adaptation; CL: Analyze When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle? 1. dysmenorrhea 2. metrorrhagia 3. oligomenorrhea 4. menorrhagia -correct answers. 3. oligomenorrhea A change in the menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is painful menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of hypothyroidism. Menorrhagia, excessive bleeding during menstrual periods, is a symptom of hypothyroidism. CN: Physiological adaptation; CL: Analyze A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? (Select all that apply.) 1. rapid pulse 2. decreased energy and fatigue 3. weight gain of 10 lbs (4.5 kg) 4. fine, thin hair with hair loss 5. constipation 6. menorrhagia. -correct answers. 2. decreased energy and fatigue, 3. weight gain of 10 lbs (4.5 kg), 5. constipation, 6. menorrhagia Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism. CN: Physiological adaptation; CL: Analyze Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following? 1. sore throat 2. painful, excessive menstruation 3. constipation 4. increased urine output -correct answers. 1. sore throat The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy. CN: Pharmacological and parenteral therapies; CL: Synthesize A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having problems at work because I lose my temper very easily." Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? 1. "Your behavior is caused by temporary confusion brought on by your illness." 2. "Your behavior is caused by the excess thyroid hormone in your system." 3. "Your behavior is caused by your worrying about the seriousness of your illness." 4. "Your behavior is caused by the stress of trying to manage a career and cope with illness." -correct answers. 2. "Your behavior is caused by the excess thyroid hormone in your system." A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is a common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed. CN: Psychosocial integrity; CL: Synthesize The nurse is evaluating a client with hyperthyroidism who is taking Propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance therapy. Which of the following statements from the client indicates the desired outcome of the drug? 1. "I have excess energy throughout the day." 2. "I am able to sleep and rest at night." 3. "I have lost weight since taking this medication." 4. "I do perspire throughout the entire day." -correct answers. 2. "I am able to sleep and rest at night." PTU is a prototype of thioamide antithyroid drugs. It inhibits production of thyroid hormones and peripheral conversion of T4 to the more active T3. A client taking this antithyroid drug should be able to sleep and rest well at night since the level of thyroid hormones is reduced in the blood. Excess energy throughout the day, loss of weight and perspiring through the day are symptoms of hyperthyroidism indicating the drug has not produced its outcome. CN: Pharmacological and parenteral therapies; CL: Evaluate. The nurse should teach the client with Graves' disease to prevent corneal irritation from mild exophthalmos by: 1. Massaging the eyes at regular intervals. 2. Instilling an ophthalmic anesthetic as prescribed. 3. Wearing dark-colored glasses. 4. Covering both eyes with moistened gauze pads. -correct answers. 3. Wearing dark-colored glasses. Treatment of mild ophthalmopathy that may accompany thyrotoxicosis includes measures such as wearing sunglasses to protect the eyes from corneal irritation. Treatment of ophthalmopathy should be performed in consultation with an ophthalmologist. Massaging the eyes will not help to protect the cornea. An ophthalmic anesthetic is used to examine and possibly treat a painful eye, not protect the cornea. Covering the eyes with moist gauze pads is not a satisfactory nursing measure to protect the eyes of a client with exophthalmos because treatment is not focused on moisture to the eye but rather on protecting the cornea and optic nerve. In exophthalmos, the retrobulbar connective tissues and extraocular muscle volume are expanded because of fluid retention. The pressure is also increased. CN: Reduction of risk potential; CL: Synthesize A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works? 1. "The RAI stabilizes the thyroid hormone levels before a thyroidectomy." 2. "The RAI reduces uptake of thyroxine and thereby improves your condition." 3. "The RAI lowers the levels of thyroid hormones by slowing your body's production of them." 4. "The RAI destroys thyroid tissue so that thyroid hormones are no longer produced." -correct answers. 4. "The RAI destroys thyroid tissue so that thyroid hormones are no longer produced." Sodium iodide 131I destroys the thyroid follicular cells, and thyroid hormones are no longer produced. RAI is commonly recommended for clients with Graves' disease, especially the elderly. The treatment results in a "medical thyroidectomy." RAI is given in lieu of surgery, not before surgery. RAI does not reduce uptake of thyroxine. The outcome of giving RAI is the destruction of the thyroid follicular cells. It is possible to slow the production of thyroid hormones with RAI. CN: Pharmacological and parenteral therapies; CL: Synthesize After treatment with radioactive iodine (RAI) in the form of sodium iodide 131I, the nurse teaches the client to: 1. Monitor for signs and symptoms of hyperthyroidism. 2. Rest for 1 week to prevent complications of the medication. 3. Take thyroxine replacement for the remainder of the client's life. 4. Assess for hypertension and tachycardia resulting from altered thyroid activity. -correct answers. 3. Take thyroxine replacement for the remainder of the client's life. The client needs to be educated about the need for lifelong thyroid hormone replacement. Permanent hypothyroidism is the major complication of RAI 131I treatment. Lifelong medical follow-up and thyroid replacement are warranted. The client needs to monitor for signs and symptoms of hypothyroidism, not hyperthyroidism. Resting for 1 week is not necessary. Hypertension and tachycardia are signs of hyperthyroidism, not hypothyroidism. CN: Pharmacological and parenteral therapies; CL: Synthesize A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The expected outcome of using this drug is that it helps: 1. Slow progression of exophthalmos. 2. Reduce the vascularity of the thyroid gland. 3. Decrease the body's ability to store thyroxine. 4. Increase the body's ability to excrete thyroxine. -correct answers. 2. Reduce the vascularity of the thyroid gland. SSKI is frequently administered before a thyroidectomy because it helps decrease the vascularity of the thyroid gland. A highly vascular thyroid gland is very friable, a condition that presents a hazard during surgery. Preparation of the client for surgery includes depleting the gland of thyroid hormone and decreasing vascularity. SSKI does not decrease the progression of exophthalmos, and it does not decrease the body's ability to store thyroxine or increase the body's ability to excrete thyroxine. CN: Pharmacological and parenteral therapies; CL: Apply The nurse is administering a saturated solution of potassium iodide (SSKI). The nurse should: 1. Pour the solution over ice chips. 2. Mix the solution with an antacid. 3. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw. 4. Disguise the solution in a pureed fruit or vegetable. -correct answers. 3. Dilute the solution with water, milk, or fruit juice and have the client drink it with a straw. SSKI should be diluted well in milk, water, juice, or a carbonated beverage before administration to help disguise the strong, bitter taste. Also, this drug is irritating to mucosa if taken undiluted. The client should sip the diluted preparation through a drinking straw to help prevent staining of the teeth. Pouring the solution over ice chips will not sufficiently dilute the SSKI or cover the taste. Antacids are not used to dilute or cover the taste of SSKI. Mixing in a puree would put the SSKI in contact with the teeth. CN: Pharmacological and parenteral therapies; CL: Apply Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The nurse does this to monitor for signs of which of the following? 1. Internal hemorrhage. 2. Decreasing level of consciousness. 3. Laryngeal nerve damage. 4. Upper airway obstruction. -correct answers. 3. Laryngeal nerve damage.