Med-Surg II HESI Exam - Set One Questions And Answers Latest Top Score.
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Med-Surg II HESI
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Med-Surg II HESI
Med-Surg II HESI Exam - Set One Questions And Answers Latest Top Score.
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 ans...
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?
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 answer. 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?
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 answer. 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 answer. 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 answer. 3. Wearing
dark-colored glasses.
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