A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?
Constipation
Sensitivity to cold
Weight gain of 4.5 kg (10 lbs) in 3 weeks
Frequent mood changes
The Correct Answer is D
Choice A Reason:
Constipation is not typically associated with hyperthyroidism. Hyperthyroidism usually speeds up the body’s metabolism, leading to symptoms like increased bowel movements or diarrhea rather than constipation.
Choice B Reason:
Sensitivity to cold is more commonly associated with hypothyroidism, where the body’s metabolism slows down. In hyperthyroidism, patients often experience heat intolerance due to an increased metabolic rate.
Choice C Reason:
Weight gain of 4.5 kg (10 lbs) in 3 weeks is also more indicative of hypothyroidism. Hyperthyroidism generally causes weight loss despite an increased appetite because of the accelerated metabolism.
Choice D Reason:
Frequent mood changes are a common symptom of hyperthyroidism. The excess thyroid hormones can affect the nervous system, leading to symptoms such as anxiety, irritability, and mood swings.
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Correct Answer is D
Explanation
Choice A reason: Don sterile gloves:
While it is important to maintain cleanliness, sterile gloves are not necessary for administering a suppository. Clean, non-sterile gloves are sufficient to prevent infection and ensure hygiene.
Choice B reason: Position the client supine with knees bent:
The correct position for administering a suppository is the left lateral (Sims) position, not supine with knees bent. The left lateral position allows for easier access to the rectum and helps the suppository stay in place.
Choice C reason: Use a rectal applicator for insertion:
Suppositories are typically inserted using a gloved finger, not a rectal applicator. The gloved finger allows for better control and ensures the suppository is placed correctly.
Choice D reason: Insert the suppository just beyond the internal sphincter:
This is correct. The suppository should be inserted past the internal sphincter to ensure it stays in place and can dissolve properly. This placement helps the medication to be absorbed effectively.
Choice E reason: Lubricate the index finger:
Lubricating the index finger is essential to make the insertion process smoother and more comfortable for the client. It helps prevent trauma to the rectal mucosa and ensures the suppository is inserted easily.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A: Evaluate for the presence of a Babinski reflex
The Babinski reflex, also known as the plantar reflex, is a normal reflex in infants up to 2 years old. When the sole of the foot is stroked, the big toe moves upward, and the other toes fan out. This reflex helps assess the neurological function and integrity of the corticospinal tract. In the context of a subdural hematoma, evaluating the Babinski reflex can help determine if there is any neurological impairment or increased intracranial pressure, which could indicate worsening of the condition.
Choice B: Measure the head circumference
Measuring the head circumference is crucial in infants, especially those with head injuries, as it helps monitor brain growth and detect any abnormal swelling or increased intracranial pressure. An increase in head circumference can indicate the presence of intracranial bleeding or edema, which requires immediate medical attention. Regular monitoring of head circumference allows healthcare providers to track the infant’s neurological development and identify any deviations from the normal growth curve.
Choice C: Assess the pupillary reaction to light
Assessing the pupillary reaction to light is an essential neurological assessment in infants with head injuries. The pupils’ response to light provides information about the function of the optic nerve and the brainstem. A normal pupillary reaction indicates that the brainstem is functioning correctly, while an abnormal reaction can suggest increased intracranial pressure or brain injury. In this case, the nurse should assess the pupillary reaction to ensure there are no signs of neurological deterioration.
Choice D: Encourage parents to feed the infant
Encouraging parents to feed the infant is not recommended in this scenario. The infant’s inability to awaken for feeding and sleeping through the vital sign assessment could indicate a decreased level of consciousness or neurological impairment. Feeding an infant in such a state could increase the risk of aspiration and further complications. Instead, the nurse should focus on monitoring the infant’s neurological status and ensuring their safety.
Choice E: Palpate fontanel level
Palpating the fontanel level is an important assessment in infants with head injuries. The fontanels, or soft spots on the infant’s skull, provide valuable information about intracranial pressure. A bulging fontanel can indicate increased intracranial pressure, while a sunken fontanel may suggest dehydration. In this case, the nurse should palpate the fontanel to assess for any abnormalities that could indicate changes in the infant’s condition.
