Med-Surg II HESI Exam - set one EXAM, MOST
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The nurse is completing a health 2. tachycardia
assessment of a 42-year-old female
with suspected Graves' Disease. The Graves' disease, the most common type of
nurse should assess this client for: thyrotoxicosis, is a state of hypermetabolism. The
increased metabolic rate generates heat and
1. anorexia produces tachycardia and fine muscle tremors.
2. tachycardia Anorexia is associated with hypothyroidism. Loss of
3. weight gain weight, despite a good appetite and adequate
4. cold skin caloric intake, is a common feature of
hyperthyroidism. Cold skin is associated with
hypothyroidism.
CN: Physiological adaptation; CL: Analyze
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When conducting a health history 3. oligomenorrhea
with a female client with
thyrotoxicosis, the nurse should ask A change in the menstrual interval, diminished
about which of the following menstrual flow (oligomenorrhea), or even the
changes in the menstrual cycle? absence of menstruation (amenorrhea) may result
from the hormonal imbalances of thyrotoxicosis.
1. dysmenorrhea Oligomenorrhea in women and decreased libido
2. metrorrhagia and impotence in men are common features of
3. oligomenorrhea thyrotoxicosis. Dysmenorrhea is painful
4. menorrhagia 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 2. decreased energy and fatigue, 3. weight gain of
with hypothyroidism. The nurse 10 lbs (4.5 kg), 5. constipation, 6. menorrhagia
should assess the client for which of
the following? (Select all that apply.) Clients with hypothyroidism exhibit symptoms
indicating a lack of thyroid hormone. Bradycardia,
1. rapid pulse decreased energy and lethargy, memory problems,
2. decreased energy and fatigue weight gain, coarse hair, constipation, and
3. weight gain of 10 lbs (4.5 kg) menorrhagia are common signs and
4. fine, thin hair with hair loss symptoms of hypothyroidism.
5. constipation
6. menorrhagia. CN: Physiological adaptation; CL: Analyze
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Propylthiouracil (PTU) is prescribed 1. sore throat
for a client with Graves' disease. The
nurse should teach the client to The most serious adverse effects of PTU are
immediately report which of the leukopenia and agranulocytosis, which usually
following? occur within the first 3 months of treatment. The
client should be taught to promptly report to the
1. sore throat health care provider signs and symptoms of
2. painful, excessive menstruation infection, such as a sore throat and fever. Clients
3. constipation having a sore throat and fever should have an
4. increased urine output 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
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A client with thyrotoxicosis says to 2. "Your behavior is caused by the excess thyroid
the nurse, "I am so irritable. I am hormone in your system."
having
problems at work because I lose my A typical sign of thyrotoxicosis is irritability caused
temper very easily." Which of the by the high levels of circulating thyroid hormones
following responses by the nurse in the body. This symptom decreases as the client
would give the client the most responds to therapy. Thyrotoxicosis does not cause
accurate explanation of her confusion. The client may be worried about her
behavior? illness, and stress may influence her mood;
however, irritability is a common symptom of
1. "Your behavior is caused by thyrotoxicosis and the client should be informed of
temporary confusion brought on by that fact rather than blamed.
your illness."
2. "Your behavior is caused by the CN: Psychosocial integrity; CL: Synthesize
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."
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