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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View Related questions
Correct Answer is A
Explanation
A) Assess urine output hourly. Monitoring urine output hourly is critical in the postoperative care of a client following a kidney transplant. It helps assess kidney function and detect any potential complications such as acute rejection or acute tubular necrosis early. Changes in urine output can provide important information about the client's fluid status and renal perfusion.
B) Check the client's blood pressure every 8 hr. While monitoring blood pressure is important, it is not sufficient to check it only every 8 hours in the immediate postoperative period. Blood pressure can fluctuate significantly due to factors such as fluid status, medication effects, and potential complications. More frequent monitoring, especially in the first 24 hours, is essential for timely intervention.
C) Monitor for hypokalemia as a manifestation of acute rejection. Hypokalemia is not typically a manifestation of acute rejection following a kidney transplant; rather, hyperkalemia is more commonly observed due to impaired kidney function. Therefore, focusing on monitoring for signs of hyperkalemia would be more relevant in this context.
D) Administer opioids PO. While pain management is crucial after surgery, opioids are often administered intravenously in the immediate postoperative period for better control and quicker action. Oral administration may be appropriate later when the client is stable and can tolerate oral medications.
Correct Answer is B
Explanation
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.