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) "Apply a second pair of gloves before touching the client's implant if it dislodges.": This is the correct action. If a sealed radiation implant dislodges, the nurse should wear a second pair of gloves to minimize exposure to radiation while handling the implant. This is a crucial safety measure to protect both the nurse and others in the environment.
B) "Limit family member visits to 30 min per day.": While it is important to limit the time family members spend with a patient who has a sealed radiation implant, the specific duration can vary based on institutional policies and the level of radiation. It may not be necessary to restrict visits to exactly 30 minutes.
C) "Give the dosimeter badge to the oncoming nurse at the end of the shift.": The dosimeter badge should not be passed to another nurse. Each nurse should wear their own badge to accurately measure their individual exposure to radiation. It should be kept by the individual nurse throughout their shifts.
D) "Remove soiled linens from the room after each change.": This statement is misleading. Soiled linens should be handled with care and may need to be treated as radioactive waste depending on the facility's protocols. They should not be removed without following proper safety and disposal guidelines.
Correct Answer is C
Explanation
A) Obtain the client's vital signs: While obtaining vital signs is important after a seizure, it is not the immediate priority during the seizure event. The focus should be on ensuring the client's safety.
B) Lower the client to the floor: Lowering the client to the floor can be a helpful action if the client is standing, but it is not the first step. If the client is already on the floor, this action may not be necessary.
C) Clear items from the client's surrounding area: This is the first action the nurse should take. Clearing the area helps prevent injury to the client during the seizure, ensuring that no objects could potentially cause harm. Safety is the immediate priority during a seizure.
D) Loosen the client's restrictive clothing: While loosening restrictive clothing can be beneficial, it is a secondary action. The primary concern during a seizure is to ensure the client's immediate safety by clearing the surrounding area.