Question

A nurse is assisting with the care of a client on a medical-surgical unit.

Answer 1

Correct Answers

Blank 1 Correct Option: Hyperthyroidism
Blank 2 Correct Option: Limit visitors to the client's room and Reduce the temperature in the client's room.
Blank 3 Correct Option: Temperature and Daily weight

Rationale :

Hyperthyroidism

💎 The client has tachycardia, fatigue, insomnia, restlessness, irritability, warm moist skin, diaphoresis, dyspnea on exertion, and muscle weakness, all classic signs of hyperthyroidism/thyrotoxicosis.

💎 The labs show elevated T3 and T4 and a low TSH, which confirms primary hyperthyroidism (thyroid overproducing hormone, pituitary suppresses TSH).

💎 The low TSH with high thyroid hormones is a hallmark pattern indicating the thyroid itself is overactive, not underactive.

💎 The client’s low-grade fever and heat intolerance also support a hypermetabolic state typical of excess thyroid hormone.

💎 Therefore, among the listed choices, hyperthyroidism is the condition that best matches both clinical signs and lab findings.

Cushing’s syndrome

💎 Cushing’s syndrome is associated with excess cortisol, leading to signs like central obesity, moon face, buffalo hump, thin extremities, striae, easy bruising, and hyperglycemia.

💎 This client’s symptoms are focused on hypermetabolism, tachycardia, heat intolerance, irritability, and elevated T3/T4, not on classic Cushingoid features.

💎 The question also provides thyroid labs, not cortisol levels, which guides us away from a cortisol-related disorder.

💎 There is no mention of weight gain, truncal obesity, purple striae, or muscle wasting commonly seen in Cushing’s.

💎 Thus, Cushing’s syndrome does not fit this presentation and is not the correct condition.

Hypoparathyroidism

💎 Hypoparathyroidism causes hypocalcemia, leading to tetany, positive Chvostek’s and Trousseau’s signs, muscle cramps, and numbness/tingling around the mouth and extremities.

💎 This client’s symptoms are hypermetabolic (tachycardia, heat intolerance, restlessness) rather than neuromuscular irritability from low calcium.

💎 The case gives thyroid function tests, not calcium or PTH levels, and does not describe spasms or tetany.

💎 Hypoparathyroidism is often seen after thyroid or parathyroid surgery, which is not mentioned here.

💎 Therefore, hypoparathyroidism does not match the data and is not the priority diagnosis.

Myxedema

💎 Myxedema refers to severe hypothyroidism, characterized by bradycardia, cold intolerance, weight gain, lethargy, constipation, dry skin, and generalized non-pitting edema.

💎 In contrast, this client has tachycardia, warm moist skin, insomnia, irritability, and elevated T3/T4 with low TSH, which are the opposite of hypothyroidism.

💎 Hypothyroid clients typically have low thyroid hormone levels and elevated TSH, not the reverse.

💎 Myxedema crisis involves hypothermia and respiratory depression, not fever and hypermetabolism.

💎 Thus, myxedema does not fit and is incorrect in this scenario.

Hypocalcemia

💎 Hypocalcemia produces neuromuscular excitability, such as muscle cramps, paresthesia, tetany, and positive Chvostek’s/Trousseau’s signs, not global hypermetabolic symptoms.

💎 This client has complaints of muscle weakness with walking and lifting, but in the context of high thyroid hormone levels, this is more consistent with thyrotoxic myopathy rather than hypocalcemia.

💎 Lab results focus on T3, T4, and TSH, not calcium or PTH, suggesting the primary problem is thyroid-related, not calcium-related.

💎 Hypocalcemia may be a concern after thyroid surgery, but there is no mention of postoperative status here.

💎 Therefore, hypocalcemia is not the best match and should not be chosen as the main condition.

Actions

Limit visitors to the client's room.

💎 In hyperthyroidism, the metabolic rate and sympathetic activity are already elevated, contributing to tachycardia, restlessness, and irritability.

💎 Excess stimulation, such as multiple visitors, noise, and excitement, can further increase heart rate and anxiety, potentially worsening symptoms or triggering thyroid storm in severe cases.

💎 Limiting visitors helps create a calm, low-stimulation environment, which is important for clients with hypermetabolic and hyperadrenergic states.

💎 A quieter room reduces physiological stress and cardiac workload, supporting stabilization of vital signs.

💎 So, limiting visitors is an appropriate nursing action to help control stimulation and support cardiovascular stability in hyperthyroidism.

Reduce the temperature in the client's room.

💎 Clients with hyperthyroidism often experience heat intolerance, warm moist skin, and diaphoresis due to an increased basal metabolic rate.

💎 A cool, comfortable room temperature helps reduce discomfort, diaphoresis, and risk of further temperature elevation.

💎 Lowering the room temperature also helps manage the client’s low-grade fever (38.4° C) and supports overall thermal comfort.

💎 Cooling the environment is a non-pharmacologic intervention that can help prevent progression toward more serious hyperthermia or thyroid storm.

💎 Therefore, reducing room temperature is a priority nursing action for a hyperthyroid client with fever and heat intolerance.

Monitor for numbness and tingling around the mouth or in the hands

💎 Monitoring for numbness and tingling around the mouth and extremities is crucial in clients at risk for hypocalcemia, such as after thyroid or parathyroid surgery.

💎 These symptoms reflect neuromuscular irritability, not the hypermetabolic state seen in hyperthyroidism.

💎 In this scenario, there is no evidence of recent neck surgery or calcium imbalance being the primary concern.

💎 The main problem is elevated thyroid hormone with hyperadrenergic signs, not low calcium.

💎 Thus, while an important assessment in some contexts, this action is not a primary intervention for this hyperthyroid client.

Cover the client with warm blankets

💎 Warm blankets are appropriate for clients who are hypothermic or hypothyroid, who typically feel cold and have decreased metabolic rates.

💎 This client, however, is febrile (38.4° C/101.2° F) and has warm, moist skin and diaphoresis, indicating they already have excess heat.

💎 Adding warm blankets would trap more heat, worsening hyperthermia and discomfort.

💎 For hyperthyroidism, the goal is to promote cooling, not warming.

💎 Therefore, covering the client with warm blankets is contraindicated and incorrect in this situation.

Look for striae and increased pigmentation

💎 Striae and increased pigmentation are more associated with Cushing’s syndrome and other endocrine conditions involving excess cortisol and ACTH, not hyperthyroidism.

💎 The client’s symptoms and labs are consistent with thyroid hormone excess, not steroid excess.

💎 While a head-to-toe assessment is always important, this specific focus does not help address the acute hypermetabolic and cardiovascular issues at hand.

💎 Priorities should remain on reducing stimulation, cooling, and monitoring key hyperthyroid parameters, not on signs of an unrelated endocrine disorder.

Parameters

Temperature

💎 Fever and heat intolerance are significant in hyperthyroidism and can be early indicators of worsening disease or impending thyroid storm.

💎 Monitoring temperature trends helps evaluate whether interventions (cool environment, medications) are effectively reducing hypermetabolic activity.

💎 A decreasing temperature suggests improvement, while rising fever can signal deterioration and the need for urgent intervention.

💎 Because hyperthyroidism increases metabolic heat production, temperature is a critical vital sign to follow closely.

💎 Therefore, temperature is a key parameter to monitor to assess the client’s response to treatment and overall progress.

Daily weight

💎 Clients with hyperthyroidism often experience weight loss despite normal or increased appetite, due to increased metabolic rate.

💎 Tracking daily weight helps determine if the hypermetabolic state is being controlled, as stabilizing or increasing weight suggests improved thyroid control.

💎 Sudden or continued weight loss may indicate inadequate treatment or worsening disease.

💎 Weight is also a useful measure of nutritional status and muscle mass, both of which can be compromised in prolonged hyperthyroidism.

💎 Thus, daily weight is an important parameter to monitor to assess clinical improvement over time.

Cortisol levels

💎 Cortisol levels are primarily monitored in conditions like Cushing’s syndrome or Addison’s disease, not straightforward hyperthyroidism.

💎 The scenario provides thyroid function tests, not adrenal labs, and there is no clinical evidence of cortisol excess.

💎 Focusing on cortisol would not directly evaluate the client’s response to hyperthyroid interventions.

💎 It would also divert attention from more relevant indicators such as vital signs, temp, weight, and thyroid symptoms.

💎 Therefore, monitoring cortisol levels is not necessary for assessing progress in this particular case.

Vitamin D level

💎 Vitamin D levels are relevant for bone health and in conditions like osteoporosis or chronic kidney disease, but they are not primary markers of acute hyperthyroid control.

💎 While long-term thyroid disease can affect bone metabolism, this scenario is focused on acute hypermetabolic signs and abnormal thyroid labs.

💎 Monitoring vitamin D would not give timely information about whether the client’s hyperthyroid state is improving or worsening.

💎 Clinically, we prioritize parameters that correlate directly with thyroid hormone effects—such as heart rate, temperature, and weight.

💎 Thus, vitamin D level is not a priority parameter to monitor for progress in this acute setting.

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Answer 2

Correct Answers:

Encourage the client to complete ADLs.

Rationale :

💎 Dantrolene is a skeletal muscle relaxant that can decrease muscle spasticity but may also cause generalized muscle weakness, so clients need to maintain as much functional independence as safely possible.

💎 Encouraging the client to complete ADLs supports mobility, strength, and self-care, helping to prevent deconditioning and maintain neuromuscular function.

💎 In multiple sclerosis, maintaining activity within tolerance is important to preserve muscle tone and joint mobility, despite fatigue.

💎 The nurse should still monitor for excessive fatigue or weakness but the overall goal is to promote safe independence, not complete inactivity.

💎 Therefore, including a plan that encourages performance of ADLs is an appropriate and therapeutic intervention.

Apply hot packs to the client's muscles.

💎 Clients with multiple sclerosis are often heat sensitive, and increased temperature can worsen neurological symptoms and exacerbations.

💎 Applying hot packs may temporarily relax muscles but can also increase fatigue, weakness, and conduction block in demyelinated nerves.

💎 Heat can worsen spasticity and neurological deficits rather than relieve them, especially if the client already has compromised mobility.

💎 Safer options typically include cooler environments and gentle stretching, rather than adding heat.

💎 Therefore, applying hot packs is not appropriate for an MS client and should not be included in the care plan.

Schedule physical therapy in the afternoon.

💎 Clients with multiple sclerosis commonly experience fatigue that worsens as the day progresses, making afternoon activity more difficult.

💎 Morning is usually the best time for physical therapy, when energy levels are highest, allowing better participation and safety.

💎 Scheduling PT in the afternoon may result in reduced tolerance, weaker effort, and increased fall risk due to fatigue.

💎 The plan of care should match energy patterns, not work against them, especially in chronic neurological conditions.

💎 Thus, intentionally scheduling PT in the afternoon is not optimal and should not be the chosen intervention.

Administer valerian to promote sleep.

💎 Valerian is an herbal supplement used as a CNS depressant for sleep, but combining it with a muscle relaxant like dantrolene could increase sedation and safety risks.

💎 Herbal remedies can also have drug interactions and should not be administered by the nurse without a specific provider order.

💎 The question focuses on nursing interventions for safe use of dantrolene, not on adding unprescribed sedatives.

💎 Safer sleep support includes sleep hygiene, environment modification, and ordered medications, rather than unsupervised herbal use.

💎 Therefore, administering valerian is not appropriate and should not be included in the plan of care.

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Answer 3

Correct Answers:

Compartment syndrome

Rationale :

🔹 Compartment syndrome occurs when increased pressure within a fascial compartment impairs circulation and nerve function, often after a cast or trauma.

🔹 Classic signs include severe pain out of proportion, pain unrelieved by medication, paresthesia (numbness/tingling), pallor, cool skin, and delayed capillary refill.

🔹 The presence of pale, cold skin with sluggish cap refill indicates compromised arterial blood flow distal to the cast.

🔹 Numbness in the fingers suggests nerve compression due to rising compartment pressure.

🔹 These findings together strongly indicate compartment syndrome, a limb-threatening emergency that requires immediate provider notification and cast adjustment or fasciotomy.

Fat embolism

🔹 Fat embolism typically occurs after long bone fractures (like femur) and presents with respiratory distress, tachypnea, hypoxia, confusion, and petechial rash on chest or upper body.

🔹 This client’s symptoms are localized to the affected arm—pain, numbness, pallor—not systemic respiratory or neurological symptoms.

🔹 There is no mention of shortness of breath, confusion, chest petechiae, or hypoxemia, which would be expected in fat embolism.

🔹 While fat embolism is a serious complication, it does not explain the cold, pale limb with sluggish capillary refill.

🔹 Therefore, fat embolism is not the best match for this presentation.

Deep vein thrombosis (DVT)

🔹 DVT typically presents with unilateral swelling, warmth, redness, and pain in a limb, most often in the lower extremities.

🔹 The problem here is cold, pale skin and neurovascular compromise under a cast, not swelling and warmth.

🔹 DVT does not usually cause numbness in the fingers or sluggish cap refill distal to a cast.

🔹 The timing and symptoms fit better with local compartment pressure rather than venous clot formation.

🔹 So, DVT is not the correct complication in this context.

Osteomyelitis

🔹 Osteomyelitis is a bone infection that usually presents with localized bone pain, warmth, swelling, redness, and systemic signs like fever and elevated WBC.

🔹 This scenario describes acute neurovascular compromise (pallor, coolness, altered cap refill) rather than infection signs.

🔹 Osteomyelitis is not an immediate, within-hours complication of a new cast; it typically develops over days to weeks, especially after open fractures or surgery.

🔹 The priority concern here is blood flow obstruction, not infection.

🔹 Therefore, osteomyelitis is not the most likely complication.

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Answer 4

Correct Answers:

Truncal obesity

Rationale :

🟣 Cushing’s syndrome results from excess cortisol, which causes fat redistribution leading to truncal (central) obesity, moon face, and buffalo hump.

🟣 Patients often have thin extremities with muscle wasting but increased fat in the abdomen, upper back, and face.

🟣 This central obesity is a hallmark physical change and is often very distressing to clients because it alters body image significantly.

🟣 Other features include purple striae, easy bruising, hypertension, and glucose intolerance, but truncal obesity is one of the most characteristic.

🟣 Therefore, truncal obesity is the best answer describing a Cushing’s-related physical change.

Hyperpigmentation of the skin

🟣 Hyperpigmentation is more typical of Addison’s disease (adrenal insufficiency) or very high ACTH states, not classic Cushing’s syndrome as tested on exams.

🟣 In Addison’s, low cortisol leads to increased ACTH, which cross-stimulates melanocytes, causing bronze or darkened skin.

🟣 Clients with Cushing’s generally have cortisol excess, not deficiency, and exam questions usually associate them with striae and bruising, not widespread hyperpigmentation.

🟣 While there can be some ACTH-related pigmentation in specific variants, that is not the standard NCLEX-style association for Cushing’s syndrome.

🟣 Thus, hyperpigmentation is not the best choice here.

Lordosis

🟣 Lordosis is an abnormal inward curvature of the lumbar spine, often seen in pregnancy, obesity, or posture issues, not specifically due to Cushing’s.

🟣 Although trunk weight can affect posture, lordosis is not a classic diagnostic sign of Cushing’s syndrome.

🟣 The question is testing recognition of hallmark endocrine physical changes, not general postural problems.

🟣 Therefore, lordosis is too nonspecific and not the best answer.

🟣 It is Cushing’s hallmark fat redistribution (truncal obesity, moon face, buffalo hump) that you should focus on.

Exophthalmos

🟣 Exophthalmos (bulging eyes) is classically associated with Graves’ disease (hyperthyroidism), not Cushing’s syndrome.

🟣 It results from autoimmune inflammation and tissue deposition behind the eyes, not from cortisol excess.

🟣 Cushing’s affects fat, protein, and glucose metabolism, causing central obesity and skin changes, but not eye protrusion.

🟣 Exams strongly link exophthalmos with thyroid disease, so choosing it for Cushing’s would be incorrect.

🟣 Thus, exophthalmos is not a Cushing’s-related physical change.

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Answer 5

Correct Answers:

"The medication should be taken before I eat breakfast every morning."

Rationale :

🟢 Levothyroxine should be taken on an empty stomach, typically 30–60 minutes before breakfast, to ensure optimal absorption.

🟢 Taking it with food, calcium, iron, or antacids can decrease absorption, making the dose less effective.

🟢 Establishing a consistent morning routine improves hormone level stability and therapeutic effect.

🟢 This statement accurately reflects the timing and administration needed for correct use.

🟢 Therefore, this is the statement that best shows correct understanding of levothyroxine administration.

"I will need to take the medication until my thyroid function returns to normal."

🟢 Most clients with hypothyroidism require lifelong thyroid hormone replacement, because the thyroid gland typically does not recover normal function.

🟢 Saying “until my thyroid function returns to normal” implies the treatment is temporary, which is usually incorrect.

🟢 Stopping the medication when they “feel better” can lead to recurrence of hypothyroid symptoms and complications.

🟢 Teaching should emphasize that levothyroxine is often a lifelong therapy with periodic TSH monitoring and dose adjustment.

🟢 Thus, this statement shows misunderstanding of the chronic nature of hypothyroidism treatment.

"The medication might lower my blood sugar."

🟢 Levothyroxine may actually increase blood glucose levels slightly because it increases metabolic rate, not lower them.

🟢 Clients with diabetes may need adjustments to antidiabetic medications when starting or changing levothyroxine.

🟢 Saying it might lower blood sugar is the opposite of the typical effect and can be misleading.

🟢 Nurses should monitor for hyperglycemia, not hypoglycemia, as a possible effect.

🟢 Therefore, this statement is incorrect.

"I will take the medication with an antacid if it gives me heartburn."

🟢 Antacids, as well as calcium and iron supplements, can interfere with levothyroxine absorption if taken at the same time.

🟢 The client should be taught to take levothyroxine on an empty stomach and separate antacids by at least 4 hours.

🟢 Taking them together may reduce drug effectiveness and lead to persistent hypothyroid symptoms.

🟢 Heartburn management must use provider-approved strategies that do not interfere with thyroid hormone therapy.

🟢 Thus, this statement indicates inadequate understanding of proper medication administration.

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Answer 6

Correct Answers:

Heart rate 120/min

Rationale :

🔶 Tachycardia is an early and important sign of worsening hypovolemia, as the body tries to compensate for decreased circulating volume.

🔶 A heart rate of 120/min is significantly elevated and suggests that volume status may still be compromised.

🔶 Persistent or worsening tachycardia can precede hypotension and shock, so it requires prompt reporting and intervention.

🔶 In the context of recent nausea and vomiting, this is a red flag that fluid replacement may be inadequate.

🔶 Therefore, the heart rate of 120/min is the most critical finding to report to the provider.

Urine output 240 mL in 8 hr

🔶 An output of 240 mL in 8 hr equals 30 mL/hr, which is at the lower limit of normal for adequate kidney perfusion.

🔶 While borderline, it still meets the minimal standard of ≥30 mL/hr, so it is not immediately alarming.

🔶 Continued monitoring is necessary, but it does not demand urgent reporting in the same way as a HR of 120/min.

🔶 If output drops below 30 mL/hr or trends down further, it would then become more concerning.

🔶 As given, this value alone does not indicate acute worsening.

Blood pressure 110/55 mm Hg

🔶 A BP of 110/55 mm Hg is within acceptable limits, especially if the client is awake and perfusing adequately.

🔶 The diastolic is slightly low, but not at a level typically associated with shock or severe hypotension.

🔶 In hypovolemia, we worry more when we see significant drops in systolic BP or narrowing pulse pressure, neither of which is dramatic here.

🔶 When compared to a HR of 120, the BP is relatively stable.

🔶 Therefore, this BP does not require the same urgency as the tachycardia.

Respiratory rate 14/min

🔶 A respiratory rate of 14/min is within the normal adult range (12–20/min).

🔶 There is no indication of respiratory distress, compensatory tachypnea, or metabolic acidosis from this value.

🔶 In hypovolemia, concerning findings would include increased RR, dyspnea, or signs of shock, none of which are present here.

🔶 As such, this RR suggests the respiratory status is currently stable.

🔶 It does not need to be reported as an abnormal or urgent finding.

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Answer 7

Correct Answers:

"Eat soft foods."

Rationale :

🥄 Stomatitis is inflammation of the oral mucosa, which makes the mouth painful, tender, and easily irritated by chewing and swallowing.

🥄 Recommending soft foods helps minimize mechanical trauma, because soft textures are gentler on the inflamed tissue and easier to chew.

🥄 Soft foods such as mashed potatoes, yogurt, pudding, scrambled eggs, and smoothies can help the client maintain adequate nutrition without worsening oral pain.

🥄 This approach supports healing and comfort, as the client is more likely to eat enough when food does not cause sharp or burning pain.

🥄 Therefore, recommending soft foods is the most appropriate and therapeutic dietary intervention for a client with stomatitis.

"Choose foods that are served hot."

🥄 Hot foods can increase irritation and pain in an already inflamed oral mucosa, making stomatitis symptoms worse.

🥄 High temperatures may cause a burning sensation over ulcerated or sensitive areas, which can discourage the client from eating.

🥄 Clients with stomatitis usually tolerate cool or cold foods better, as they can feel soothing and reduce discomfort during meals.

🥄 Heat can also prolong inflammation and delay healing of the mucosal lining.

🥄 Because the goal is to reduce irritation and pain, hot foods are not recommended for clients with stomatitis.

"Season foods with salt."

🥄 Salt acts as a chemical irritant when applied to open sores or inflamed tissue, causing a sharp burning or stinging sensation.

🥄 Adding extra salt to food will likely make oral pain from stomatitis worse, leading to reduced intake because eating becomes more uncomfortable.

🥄 For a client with stomatitis, the diet should be bland and non-irritating, avoiding salty, spicy, or acidic foods.

🥄 Increasing salt does not promote healing and may instead contribute to further inflammation and mucosal breakdown.

🥄 Therefore, telling the client to “season foods with salt” is contraindicated and should not be recommended.

"Select foods that are low in protein."

🥄 Protein is essential for tissue repair and healing, including the healing of inflamed or ulcerated oral mucosa in stomatitis.

🥄 Advising a diet low in protein can impair the body’s ability to repair damaged tissue, potentially delaying healing.

🥄 The problem in stomatitis is pain and irritation, not an intolerance to protein, so the focus should be on texture and irritants, not cutting protein.

🥄 Clients should actually maintain adequate protein intake with soft, non-irritating protein sources such as yogurt, cottage cheese, or soft eggs.

🥄 Therefore, recommending a low-protein diet is inappropriate and not therapeutic for a client with stomatitis.

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Answer 8

Correct Answers:

Notify the charge nurse of the client's blood pressure.

Rationale :

Notify the charge nurse of the client's blood pressure.

🔶 The client’s blood pressure dropped from 118/62 to 90/55 mm Hg within 4 hours, while the heart rate increased from 96/min to 105/min, which indicates worsening hypovolemia due to ongoing nausea and vomiting.

🔶 Hypotension with compensatory tachycardia is a red-flag sign that the client’s circulating volume is decreased, and they are at risk for progressing to shock if not treated.

🔶 The client also has decreased skin turgor and dry mucous membranes, further supporting fluid volume deficit even though electrolytes and kidney values are still within normal limits.

🔶 Because this is an acute change in vital signs that signals hemodynamic instability, the nurse must promptly notify the charge nurse and provider so that IV fluids or other interventions can be initiated.

🔶 This action aligns with nursing priorities to address circulation and perfusion first, making this the most appropriate and urgent response.

Encourage the client to ambulate independently.

🔶 With a blood pressure of 90/55 mm Hg and a heart rate of 105/min, the client is already showing signs of hemodynamic compromise and compensatory tachycardia.

🔶 Encouraging independent ambulation in this state increases the risk of dizziness, syncope, or falls, because perfusion to the brain may be reduced when the client stands or walks.

🔶 Activity should be limited until the client’s volume status and blood pressure are more stable, especially in the setting of recent fluid loss from vomiting.

🔶 The priority is to stabilize circulation, not to push mobility, which can further stress the cardiovascular system.

🔶 Therefore, encouraging independent ambulation at this time is unsafe and inappropriate.

Administer an antipyretic medication.

🔶 The client’s temperature decreased from 37.7° C (99.9° F) to 37.2° C (99° F), which are both within the low-grade or near-normal range, and not indicative of a clinically significant fever that requires antipyretics.

🔶 The primary concern in this scenario is not temperature, but the drop in blood pressure and rising heart rate, which indicate worsening hypovolemia.

🔶 Giving an antipyretic does nothing to correct the client’s fluid volume deficit or hemodynamic changes.

🔶 Focusing on a mild or resolving temperature distracts from the more urgent circulatory issue that can rapidly lead to shock if untreated.

🔶 Thus, administering an antipyretic is not appropriate or necessary in this situation.

Keep the temperature in the client's room warm.

🔶 There is no indication that the client is hypothermic or complaining of being cold; their temperature is near normal, and thermoregulation is not the primary issue.

🔶 The client is experiencing fluid volume loss from nausea and vomiting, and the critical concern is maintaining perfusion, not environmental warmth.

🔶 Keeping the room warm does not address the low blood pressure, tachycardia, dry mucous membranes, or poor skin turgor.

🔶 In some hypovolemic states, excessive warmth could even contribute to further discomfort or relative vasodilation, although that’s not the main exam focus here.

🔶 Therefore, adjusting room temperature is not an effective or priority response to the client’s current clinical status.

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Answer 9

Correct Answers:

Remind the client to avoid watching their feet when walking.

Rationale :

🧠 Clients with Parkinson’s disease have shuffling gait, postural instability, and a high risk of falls.

🧠 Teaching the client to look straight ahead instead of at their feet helps maintain better posture and balance while walking.

🧠 When clients stare at their feet, they can become more flexed forward, worsening instability and freezing episodes.

🧠 Focusing ahead also allows them to scan the environment, avoid obstacles, and use visual cues to improve gait.

🧠 Therefore, reminding the client to avoid watching their feet when walking is an important safety and mobility strategy in Parkinson’s disease.

"Place the client on a low-calorie diet to prevent weight gain."

🧠 Clients with Parkinson’s disease are more prone to weight loss than weight gain due to tremors, rigidity, swallowing difficulties, and increased energy use.

🧠 A low-calorie diet may worsen malnutrition and muscle wasting, which can further impair mobility and strength.

🧠 The focus is usually on nutrient-dense foods, adequate calories, and sometimes modified texture for dysphagia.

🧠 Weight maintenance or gain is often desired, not restriction, especially as the disease progresses.

🧠 Therefore, recommending a low-calorie diet is not appropriate for most Parkinson’s clients.

"Remind the client to take tub baths instead of showers."

🧠 Getting in and out of a tub requires significant strength, balance, and flexibility, which are often impaired in Parkinson’s disease.

🧠 Tub baths increase the risk of slipping, falling, or becoming stuck, especially with rigidity and bradykinesia.

🧠 Showers with grab bars, non-slip mats, and a shower chair are much safer options.

🧠 Safety teaching should aim to minimize complex transfers and sudden movements that can destabilize the client.

🧠 Therefore, advising tub baths is unsafe and should not be included in teaching.

"Use small area rugs in the client’s home for traction."

🧠 Small area rugs are a major fall hazard, especially for clients with shuffling gait or freezing.

🧠 Parkinson’s clients may drag their feet, easily catching them on rug edges and causing falls.

🧠 Safety teaching often includes removing loose rugs and clutter to provide clear, flat walking surfaces.

🧠 If traction is needed, non-slip flooring or secure carpeting is safer than small scattered rugs.

🧠 Thus, using small area rugs is contraindicated and should not be recommended.

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Answer 10

Correct Answers:

Loosen clothing around the client's neck.

Rationale :

⚡ During a tonic–clonic seizure, the priority is to maintain airway and breathing and prevent injury, not to stop the movements.

⚡ Loosening clothing around the neck reduces restriction, promotes easier chest expansion and airway patency, and prevents strangulation or impaired ventilation.

⚡ This simple action helps ensure that the client can breathe more freely while the seizure runs its course.

⚡ It is a non-invasive, safe intervention that aligns with standard seizure precautions.

⚡ Therefore, loosening clothing around the neck is an appropriate and priority nursing action.

"Lower the side rails of the client's bed."

⚡ Lowering the side rails during a seizure increases the risk that the client could fall out of bed and sustain injury.

⚡ Instead, side rails should be up and padded if possible to protect the client from hitting the rails.

⚡ The goal is to keep the client safe where they are, not allow them to fall to the floor.

⚡ Lower rails remove an important safety boundary during uncontrolled body movements.

⚡ Thus, lowering the side rails is not appropriate in this situation.

"Apply wrist restraints to the client."

⚡ Applying restraints during a seizure can cause musculoskeletal injury, including sprains or fractures, because the movements are strong and involuntary.

⚡ Restraining the limbs does not stop the seizure and may increase risk of trauma to joints and soft tissues.

⚡ Standard care is to protect the head, maintain airway, and ensure a safe environment, not to restrain the person.

⚡ It is also psychologically and ethically inappropriate to restrain a seizing client unless there is an absolutely compelling reason and proper order, which is not evident here.

⚡ Therefore, applying wrist restraints is contraindicated.

"Position the client in the semi-Fowler's position."

⚡ In an active tonic–clonic seizure, the nurse should avoid trying to reposition the client extensively, as this can cause injury.

⚡ Semi-Fowler’s is not ideal for airway protection; instead, side-lying (lateral) position after the seizure is recommended to help drain secretions and prevent aspiration.

⚡ During the seizure, the nurse should turn the client’s head to the side if possible, not prop them up.

⚡ Attempting to raise the head of bed during violent movements can be unsafe for both client and nurse.

⚡ Thus, positioning in semi-Fowler’s is not the correct immediate action.

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ATI PN Adult Medical Surgical Online Practice 2023 B

No.

1 :
A nurse is assisting with the care of a client on a medical-surgical unit.

Correct Answers

2 :
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include?

4 :
A nurse is assisting with the care for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder?

5 :
A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

7 :
A nurse is assisting with the care for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?

8 :
Patient's data.

Answer Options

9 :
A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

10 :
A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

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ATI PN Adult Medical Surgical Online Practice 2023 B

No.

1 : A nurse is assisting with the care of a client on a medical-surgical unit.

Correct Answers

2 : A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include?

4 : A nurse is assisting with the care for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder?

5 : A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

6 : A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

7 : A nurse is assisting with the care for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?

8 : Patient's data.

Answer Options

9 : A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

10 : A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

1 :
A nurse is assisting with the care of a client on a medical-surgical unit.

2 :
A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include?

4 :
A nurse is assisting with the care for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder?

5 :
A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

6 :
A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

7 :
A nurse is assisting with the care for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?

8 :
Patient's data.

9 :
A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

10 :
A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?