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) Negative sputum cultures for acid-fast bacillus: This is the primary indicator that a client with pulmonary tuberculosis is no longer infectious. Once the sputum cultures are negative for acid-fast bacilli on two consecutive tests, the client is considered to have a reduced risk of transmitting the infection to others.
B) Mantoux skin test revealing an induration of less than 1 mm: A negative Mantoux test (induration of less than 5 mm) indicates that the person has not been exposed to TB or does not have an active infection. However, this test is not used to determine infectiousness and may not be relevant for someone already diagnosed with TB.
C) Client no longer coughing up blood-tinged sputum: While the absence of blood-tinged sputum may indicate improvement, it does not necessarily mean the client is no longer infectious. Infectiousness is more accurately assessed through sputum cultures.
D) Positive Quantiferon-TB Gold test (negative): The Quantiferon-TB Gold test is a blood test that can indicate TB infection but does not determine whether the client is infectious. A positive result can occur even when a client is being effectively treated for tuberculosis.
Correct Answer is ["A","B","C","D"]
Explanation
A) Place the client in an upright sitting position: This is the first step because it helps to lower blood pressure by promoting venous return and decreasing the effects of increased sympathetic activity associated with autonomic dysreflexia. Immediate positioning can alleviate acute symptoms and prevent further complications.
B) Confirm that the client's bladder is empty: After ensuring the client is positioned appropriately, the next step is to check for urinary retention, which is a common trigger for autonomic dysreflexia. If the bladder is full, it can exacerbate the condition, so emptying it is crucial.
C)Indicate the risk for autonomic dysreflexia in the client's medical record: While this step is important for ongoing patient care and documentation, it is not an immediate priority during an acute episode of autonomic dysreflexia. Documenting the risk should occur after addressing the client's immediate needs to ensure their safety and well-being
D)Administer an antihypertensive medication intravenously: If the client's blood pressure remains elevated after positioning and emptying the bladder, the next step is to provide pharmacological intervention. Administering an antihypertensive medication can help manage and stabilize the client's blood pressure effectively.