Page 1439 - Saunders Comprehensive Review For NCLEX-RN

Rationale: In the client with type 2 diabetes mellitus, an elevated temperature
may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic
syndrome in the client with type 2 diabetes mellitus. The other findings are within
normal limits.
Test-Taking Strategy: Note the strategic word, priority. Use knowledge of the
normal values of vital signs to direct you to the correct option. The client’s
temperature is the only abnormal value. Remember that an elevated temperature can
indicate an infectious process that can lead to complications in the client with
diabetes mellitus.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Endocrine
Health Problem: Adult Health: Endocrine: Diabetes Mellitus
Priority Concepts: Glucose Regulation; Infection
Reference: Lewis et al. (2017), p. 1145.

509. Answer: 3, 4, 5, 6

Rationale: Feeling cold, hair loss, lethargy, and facial puffiness are signs of
hypothyroidism. Tremors and weight loss are signs of hyperthyroidism.
Test-Taking Strategy: Focus on the subject, signs and symptoms associated with
hypothyroidism. Options 1 and 2 can be eliminated if you remember that in
hypothyroidism there is an undersecretion of thyroid hormone that causes the
metabolism to slow down.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Endocrine
Health Problem: Adult Health: Endocrine: Thyroid Disorders
Priority Concepts: Client Education; Clinical Judgment
Reference: Lewis et al. (2017), pp. 1168-1169.

510. Answer: 3

Rationale: Thyroidectomy is the removal of the thyroid gland, which is located in
the anterior neck. It is very important to monitor airway status, as any swelling to
the surgical site could cause respiratory distress. Although all of the options are
important for the nurse to monitor, the priority nursing action is to monitor the
airway.
Test-Taking Strategy: Note the strategic word, priority. Use the ABCs—airway,
breathing, and circulation, to assist in directing you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Endocrine
Health Problem: Adult Health: Endocrine: Thyroid Disorders

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