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 B
Explanation
Choice A reason:
Inserting a nasogastric tube is not the first-line intervention for postoperative nausea and vomiting (PONV). This invasive procedure is typically reserved for severe cases where other interventions have failed.
Choice B reason:
Administering an antiemetic is the appropriate action. Antiemetics help control nausea and vomiting, which are common side effects of opioids like morphine. This intervention can provide immediate relief and improve the client’s comfort.
Choice C reason:
Auscultating bowel sounds is important for assessing gastrointestinal function, but it does not directly address the immediate symptom of nausea and vomiting. This assessment can be part of the overall evaluation but is not the primary intervention.
Choice D reason:
Encouraging the client to ambulate is beneficial for overall recovery and can help reduce the risk of complications such as deep vein thrombosis. However, it does not directly address the immediate issue of nausea and vomiting.