A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
Decreased heart rate
Increased temperature
Lethargy
Hypotension
The Correct Answer is B
A) Decreased heart rate: In thyroid storm, the heart rate typically increases due to elevated levels of thyroid hormones. A decreased heart rate would not be characteristic of this condition.
B) Increased temperature: One of the hallmark signs of thyroid storm is hyperthermia or increased body temperature, often exceeding 101°F (38.3°C). This is due to the heightened metabolic state caused by excess thyroid hormones.
C) Lethargy: While lethargy can occur in other thyroid-related issues, thyroid storm is more commonly associated with hyperactivity and agitation rather than lethargy. Clients may present with restlessness and confusion.
D) Hypotension: In thyroid storm, clients often experience hypertension rather than hypotension. The increased metabolic demands can lead to elevated blood pressure due to increased cardiac output and peripheral vasodilation.
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Explanation
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Flumazenil: This medication is a benzodiazepine antagonist and is used to reverse the effects of benzodiazepines. It is not effective for opioid overdose or respiratory depression caused by morphine.
Naloxone: Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, including respiratory depression. In cases of opioid-induced respiratory depression, naloxone is the appropriate medication to administer to restore normal respiratory function.
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Correct Answer is A
Explanation
A) Slow infusion rate and contact the provider: The client is exhibiting signs of fluid overload, as evidenced by dyspnea and a relatively high blood pressure, along with a significant positive fluid balance (960 mL intake versus 300 mL output). Slowing the infusion rate allows for better management of fluid status, while contacting the provider is crucial to reassess the treatment plan and address potential complications.
B) Change infusion to lactated Ringer's and maintain rate: This action is inappropriate because the underlying issue appears to be fluid overload rather than the type of fluid being administered. Changing the infusion to a different type of fluid does not address the need to manage the current fluid overload situation.
C) Administer prescribed corticosteroids: While corticosteroids may be indicated for certain conditions, in this scenario, the priority is addressing the client's immediate signs of fluid overload rather than administering corticosteroids without further assessment.
D) Lower the head of the bed to semi-Fowler's: While positioning the client to promote comfort and ease breathing is important, the more critical intervention is to address the infusion rate and contact the provider regarding the client’s deteriorating condition. Lowering the head of the bed does not address the underlying problem of fluid overload.