Question

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

Answer 1

Correct Answers:

Serum TSH

Rationale :

🧪Thyroid Stimulating Hormone (TSH) is elevated in primary hypothyroidism because the pituitary gland is attempting to stimulate a poorly functioning thyroid gland to produce more thyroid hormones.

❌The negative feedback loop is disrupted, resulting in increased TSH due to low circulating levels of T3 and T4.

📈A high TSH with low T3 and T4 levels is the hallmark diagnostic indicator for primary hypothyroidism.

💉Serum thyroxine (T4) and triiodothyronine (T3) are typically decreased, not elevated, in this condition.

📌Core Message

In primary hypothyroidism, the thyroid fails to produce adequate hormones, triggering a compensatory elevation in TSH by the pituitary gland due to lack of negative feedback.

Answer 2

Correct Answers:

A red, dull, thick, and immobile tympanic membrane.

Rationale :

👂Mastoiditis is a bacterial infection of the mastoid bone and often causes middle ear inflammation, which affects the tympanic membrane.

🔥The tympanic membrane typically becomes red, thickened, dull, and immobile due to fluid or pus buildup behind it.

🔬These findings are consistent with acute otitis media, a frequent precursor or co-condition with mastoiditis.

🩺A healthy tympanic membrane would be pearly, pinkish-gray, translucent, and mobile—not matching the description of an inflamed one.

📌Core Message

In mastoiditis, the tympanic membrane appears red, thick, and immobile due to associated middle ear infection and inflammation.

Answer 3

Correct Answers:

Renal Calculi

Rationale :

🪨Parathyroid hormone (PTH) increases calcium reabsorption from the bones and kidneys, resulting in hypercalcemia.

🧬Elevated calcium levels can lead to renal calculi (kidney stones) because the excess calcium precipitates in the renal tubules.

⚠️This is a common and serious complication of hyperparathyroidism, requiring close monitoring of calcium levels and kidney function.

🚱Patients may be advised to increase fluid intake and reduce calcium-rich foods to prevent stone formation.

📌Core Message

Increased PTH levels raise blood calcium, leading to a high risk of renal calculi due to calcium deposition in the kidneys.

Answer 4

Correct Answers:

Baked fish

Rationale :

🐟Baked fish is rich in iodine, an essential nutrient for thyroid hormone production, which is deficient in hypothyroidism.

🌿Iodine is required for the synthesis of both T3 and T4 hormones, which are typically low in hypothyroid patients.

🥗This dietary source supports thyroid function more effectively than fiber-rich or sugary foods, which can interfere with absorption or slow metabolism.

🛑Bran can interfere with the absorption of thyroid medications, and cantaloupe lacks essential iodine.

📌Core Message

Clients with hypothyroidism benefit from iodine-rich foods like baked fish to support thyroid hormone synthesis.

Answer 5

Correct Answers:

Glasgow Coma Scale

Rationale :

🧠The Glasgow Coma Scale (GCS) provides a standardized method to assess consciousness and cerebral function by evaluating eye, verbal, and motor responses.

🧾It is a critical tool used especially in clients with altered levels of consciousness, such as those in an induced coma.

📊Tracking GCS scores helps determine neurological deterioration or improvement and guides medical interventions.

👁️While pupil reaction is important, it mainly assesses brainstem function, not overall cerebral activity.

📌Core Message

The Glasgow Coma Scale is the primary tool to evaluate cerebral function in comatose clients and monitor neurological status.

Answer 6

Correct Answers:

Restriction of fluids

Rationale :

💧In SIADH, excessive antidiuretic hormone (ADH) leads to water retention, causing dilutional hyponatremia.

🚱The cornerstone of management is fluid restriction to prevent further sodium dilution and cerebral edema.

🧪Clients often show low serum sodium, low osmolality, and concentrated urine despite normal or increased fluid volume.

⚠️Rapid IV fluid administration or increased oral intake can worsen fluid overload and hyponatremia symptoms like confusion or seizures.

📌Core Message

In SIADH, fluid restriction is essential to prevent hyponatremia and cerebral complications from water retention.

Answer 7

Correct Answers:

Hypertension
Family history
Obesity
Increasing age

Rationale :

🧓Aging is a leading risk factor for cataracts due to protein changes in the lens over time.

👨‍👩‍👧‍👦A family history suggests a genetic predisposition to cataract formation.

📈Hypertension and obesity contribute to metabolic stress and oxidative damage, accelerating lens clouding.

😎Wearing sunglasses is a protective factor, not a risk—UV light exposure, when unprotected, increases cataract risk.

📌Core Message

Risk factors for cataracts include age, hypertension, obesity, and family history due to their impact on lens protein structure and eye health.

Answer 8

Correct Answers:

Implementing fall precautions

Rationale :

⚖️Cushing's syndrome leads to muscle weakness, osteoporosis, and hypertension, increasing fall risk significantly.

🦴Clients often have fragile bones and poor balance, making fall prevention a priority nursing action.

🏥Safety measures such as call lights, assistance with ambulation, and removing tripping hazards should be implemented early.

😷Although infection risk is high due to immunosuppression, falls pose immediate danger with severe outcomes like fractures or head injury.

📌Core Message

For clients with Cushing’s syndrome, fall prevention is a top priority due to muscle weakness and osteoporosis.

Answer 9

Correct Answers:

Hypocalcemia

Rationale :

✋Chvostek’s sign is a classic indicator of hypocalcemia, often seen after thyroid surgery due to parathyroid gland damage or removal.

⚡Hypocalcemia causes neuromuscular excitability, which leads to twitching of facial muscles when the facial nerve is tapped.

🦴The parathyroids regulate calcium homeostasis, and their compromise leads to decreased calcium levels.

🧪Calcium monitoring is critical postoperatively, especially within 24–48 hours of a thyroidectomy.

📌Core Message

Chvostek’s sign indicates hypocalcemia, a common complication after thyroid surgery due to parathyroid disruption.

Answer 10

Correct Answers:

An 80-year-old female who takes steroids daily.

Rationale :

🧓Chronic daily steroid use suppresses the hypothalamic-pituitary-adrenal (HPA) axis, reducing natural cortisol production.

🔁This makes the body unable to respond to stress or illness, increasing the risk for adrenal insufficiency.

📉Symptoms may include fatigue, hypotension, hyponatremia, and hypoglycemia, especially during times of physiological stress.

⚠️The elderly are particularly vulnerable due to decreased physiological reserve and the cumulative impact of long-term steroid use.

📌Core Message

Elderly clients on long-term steroids are at the highest risk for adrenal insufficiency due to HPA axis suppression and reduced stress response.

1 :
A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

2 :
The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

3 :
A nurse is caring for a client who has elevated parathyroid hormone levels (PTH). The nurse is aware that the client is at high risk for which condition?

4 :
A nurse is assisting a client diagnosed with hypothyroidism with meal planning. Which of the following foods should the nurse recommend that the client add to the diet?

5 :
A nurse is caring for a client in an induced coma for increased intracranial pressure (ICP). What should the nurse assess next to determine this client's cerebral function?

6 :
A client is admitted for treatment of the Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The nurse should initiate which of the following interventions?

7 :
A nurse is preparing information about eye health for a community health fair. Which of the following information related to risk factors for cataracts should the nurse include? (Select all that apply)

8 :
The nurse is caring for a client diagnosed with Cushing's Syndrome. Which of the following actions should be the nurse's highest priority?

9 :
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse assesses for the presence of Chvostek's sign to indicate which of the following electrolyte imbalances?

10 :
A nurse is screening clients for adrenal insufficiency. The nurse recognizes that which client is at greatest risk for adrenal insufficiency?

1 : A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

2 : The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

3 : A nurse is caring for a client who has elevated parathyroid hormone levels (PTH). The nurse is aware that the client is at high risk for which condition?

4 : A nurse is assisting a client diagnosed with hypothyroidism with meal planning. Which of the following foods should the nurse recommend that the client add to the diet?

5 : A nurse is caring for a client in an induced coma for increased intracranial pressure (ICP). What should the nurse assess next to determine this client's cerebral function?

6 : A client is admitted for treatment of the Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The nurse should initiate which of the following interventions?

7 : A nurse is preparing information about eye health for a community health fair. Which of the following information related to risk factors for cataracts should the nurse include? (Select all that apply)

8 : The nurse is caring for a client diagnosed with Cushing's Syndrome. Which of the following actions should be the nurse's highest priority?

9 : A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse assesses for the presence of Chvostek's sign to indicate which of the following electrolyte imbalances?

10 : A nurse is screening clients for adrenal insufficiency. The nurse recognizes that which client is at greatest risk for adrenal insufficiency?

1 :
A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

2 :
The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe?

3 :
A nurse is caring for a client who has elevated parathyroid hormone levels (PTH). The nurse is aware that the client is at high risk for which condition?

4 :
A nurse is assisting a client diagnosed with hypothyroidism with meal planning. Which of the following foods should the nurse recommend that the client add to the diet?

5 :
A nurse is caring for a client in an induced coma for increased intracranial pressure (ICP). What should the nurse assess next to determine this client's cerebral function?

6 :
A client is admitted for treatment of the Syndrome of Inappropriate Antidiuretic Hormone (SIADH). The nurse should initiate which of the following interventions?

7 :
A nurse is preparing information about eye health for a community health fair. Which of the following information related to risk factors for cataracts should the nurse include? (Select all that apply)

8 :
The nurse is caring for a client diagnosed with Cushing's Syndrome. Which of the following actions should be the nurse's highest priority?

9 :
A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse assesses for the presence of Chvostek's sign to indicate which of the following electrolyte imbalances?

10 :
A nurse is screening clients for adrenal insufficiency. The nurse recognizes that which client is at greatest risk for adrenal insufficiency?