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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Correct Answer is A
Explanation
A) Decreased anxiety: Morphine is an opioid analgesic that not only alleviates pain but also has anxiolytic properties, helping to reduce anxiety and promote a sense of well-being. In the context of acute heart failure, clients often experience anxiety due to the sensation of breathlessness and overall distress. Therefore, a noticeable decrease in anxiety levels indicates that the morphine is providing therapeutic relief and contributing positively to the client's emotional state.
B) Emesis of 250 mL: While nausea and vomiting can occur with morphine administration, emesis is generally considered an adverse effect rather than an indication of the medication's effectiveness. In fact, significant vomiting can lead to further complications, such as dehydration or electrolyte imbalances, and may require intervention. Therefore, emesis does not reflect the intended therapeutic outcomes of morphine.
C) Increased respiratory rate to 26/min: An increased respiratory rate may signal distress or inadequate ventilation, which can be concerning in a client with acute heart failure. While morphine can cause respiratory depression in some cases, an elevated respiratory rate may indicate that the client is still experiencing discomfort or hypoxia, suggesting that the medication may not have been effective in alleviating their symptoms.
D) Decreased urinary output: Decreased urinary output can be a sign of renal impairment or fluid overload, which may be exacerbated by heart failure rather than an indication of morphine's effectiveness. In the setting of acute heart failure, monitoring urinary output is essential, but a reduction does not reflect the success of morphine therapy and may warrant further evaluation and intervention.
Correct Answer is A
Explanation
A) "Use a raised toilet seat to maintain your hips above your knees.": This statement is appropriate because using a raised toilet seat helps prevent hip flexion beyond 90 degrees, which is crucial for clients recovering from a total hip arthroplasty. Maintaining proper positioning helps reduce the risk of dislocation and promotes safe mobility.
B) "Apply a heating pad to the operative hip to decrease pain.": While heat may provide comfort, it is generally advised to avoid applying heat directly to the surgical site, especially in the immediate postoperative period. Cold therapy is often recommended initially to reduce swelling and pain.
C) "Move your stronger leg first when using a walker.": This statement is incorrect for total hip arthroplasty patients. Typically, they should lead with the operated leg when using a walker to maintain proper alignment and safety during ambulation.
D) "Twist at the waist when standing from a seated position.": This instruction is inappropriate as twisting at the waist can increase the risk of dislocating the hip joint. Clients are generally advised to keep their body aligned and avoid twisting movements during the initial recovery period.