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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A) Fever: While fever can occur in various allergic reactions, it is not a specific indicator of anaphylaxis. It may signal an infection or other inflammatory process rather than an immediate hypersensitivity reaction.
B) Laryngeal edema: This is a hallmark sign of anaphylaxis. It indicates swelling in the throat that can compromise the airway, making it a critical and life-threatening response. Immediate recognition and intervention are necessary to ensure the client's airway remains patent.
C) Hypertension: Although anaphylaxis can sometimes lead to hypotension due to vascular collapse, hypertension is not typically a sign of anaphylaxis. Instead, hypotension is more commonly associated with severe allergic reactions.
D) Arrhythmia: While arrhythmias can occur due to various causes, including stress or electrolyte imbalances, they are not a direct indicator of anaphylaxis. Anaphylaxis primarily presents with respiratory symptoms, skin reactions, and gastrointestinal symptoms, rather than primarily affecting heart rhythm.
Correct Answer is B
Explanation
A) "Clean the spacer daily with cold water": While it is important to clean the spacer regularly to prevent bacterial growth, the recommendation is usually to clean it weekly with warm, soapy water rather than daily with cold water. This detail is essential for effective use but not the most critical point during initial teaching.
B) "Hold your breath for 10 seconds once you inhale": This statement is key to ensuring effective medication delivery. Holding the breath for about 10 seconds allows the medication to settle in the lungs, maximizing its therapeutic effects. This information is crucial for the client to understand the proper technique for using the inhaler with a spacer.
C) "Wait 30 seconds between puffs": While it is advisable to wait for a brief period between puffs to allow the first dose to be effective, the recommended wait time is generally around 1 minute, particularly if using a different medication or if instructed by the healthcare provider. Therefore, stating 30 seconds may be misleading.
D) "The spacer should make a whistling sound as you inhale": A whistling sound during inhalation may indicate that the spacer is being used incorrectly or that the client is inhaling too forcefully. The absence of a whistling sound is often a sign of proper technique. Therefore, this statement is misleading and not appropriate teaching for effective inhaler use.