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) "Floss your teeth gently following each meal.": This instruction is appropriate for a client with mucositis. Gentle flossing can help maintain oral hygiene and reduce the risk of infection without causing additional trauma to the already sensitive mucous membranes. It's important to emphasize a gentle approach to minimize discomfort.
B) "Rinse your mouth with hydrogen peroxide.": Rinsing with hydrogen peroxide is not recommended for clients with mucositis, as it can be irritating to the mucous membranes and exacerbate discomfort. Alternatives such as saline or baking soda rinses are typically suggested instead.
C) "Wear your dentures only during meals.": While this may seem practical, clients with mucositis are often advised to avoid dentures altogether if possible, as they can irritate the mucosa. Instead, they should be encouraged to keep their mouth clean and free of irritants.
D) "Brush your teeth for 60 seconds twice daily.": Although maintaining oral hygiene is important, brushing for only 60 seconds may not be sufficient to ensure proper cleaning, especially in the presence of mucositis. It may also be painful, leading to avoidance. A gentler and more thorough approach is often advised, using a soft-bristled toothbrush.