While assessing a client, the nurse notes the client is ...

[PhilipSeeMore]

While assessing a client, the nurse notes the client is irritable, anxious, and has lost 12 pounds over the last two months. The client's eyes appear to bulge from their sockets. Based on this data, which assessment findings does the nurse anticipate for
 
  Select all that apply.
  1. Blood pressure: 162/92 mmHg.
  2. Apical pulse: 120.
  3. Respiratory rate is 10 breaths per minute
  4. Pupils: constricted.
  5. Client complains of feeling very warm.

Question 2

The nurse is preparing to assess an adult client. The focus of the exam will be on the head and neck. Which statement by the nurse is appropriate when preparing the client for the thyroid examination?
 
  1. Please lie down while I assess your thyroid gland.
  2. When I assess your thyroid gland, you can expect to feel strong pressure.
  3. I will stand behind you while palpating your thyroid gland.
  4. Please chew this mint so that I can assess your thyroid gland.

[sarah_brady415]

Answer to Question 1

Correct Answer: 1, 2, 5
When the sympathetic nervous system is stimulated due to hyperthyroidism, the client's blood pressure, heart rate, and body temperature will increase. Complaints of feeling warm are related to increased body temperature. The client with hyperthyroidism will demonstrate an increased respiratory rate. A normal respiratory rate is 12-20 per minute. The client with hyperthyroidism will demonstrate pupil dilation.

Answer to Question 2

Correct Answer: 3

The nurse will stand behind the client while palpating the thyroid gland. The client is either asked to sit on the exam table or stand up during a thyroid gland assessment. Lying down will not allow the nurse to complete an accurate assessment of the thyroid gland. The nurse will apply light pressure, not strong pressure, during thyroid gland palpation. The nurse would ask the client to swallow water to distinguish the thyroid from other structures. Chewing a mint would be appropriate to assess certain cranial nerves.

[PhilipSeeMore]

Thank you

[sarah_brady415]

Happy to help you