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) "I can assist you with making a list of foods you like for the dietitian.": This statement encourages the client to take an active role in their dietary management by involving them in the process of planning their meals. It fosters collaboration and empowers the client to express their preferences, making it more likely they will adhere to the dietary recommendations.
B) "I understand that the dietary choices can seem overwhelming.": While this statement acknowledges the client's feelings, it does not actively promote their involvement in the care plan. It reflects empathy but lacks the encouragement needed for the client to engage in managing their diabetes.
C) "Managing your diabetes will require you to make accommodations.": This statement emphasizes the need for change but may come across as directive and could potentially discourage the client. It doesn't foster a sense of partnership in the decision-making process.
D) "The dietitian will provide you with the best food choices to manage your diabetes.": Although this statement highlights the dietitian's expertise, it places the responsibility solely on the dietitian and does not encourage the client to participate in their own dietary decisions. Engaging the client in the conversation is key to enhancing their motivation and compliance.
Correct Answer is D
Explanation
A) 10: A score of 10 on the Glasgow Coma Scale (GCS) indicates a moderate level of impairment in consciousness. This score typically includes a range of responses in eye opening, verbal, and motor responses. Given the client's specific symptoms, this score does not accurately reflect their condition.
B) 13: A GCS score of 13 indicates mild impairment. This score usually requires the ability to open eyes spontaneously, follow commands, and exhibit appropriate verbal responses. Since the client is not opening their eyes and only making incomprehensible sounds, this score is not applicable.
C) 2: A score of 2 on the GCS would imply a severely compromised response, but it would be misleading since the client exhibits decerebrate posturing, which is a significant motor response indicating a level of neurological function. Thus, this score does not adequately represent the client's status.
D) 5: This is the correct score. The GCS includes a score of 1 for no eye opening, 2 for incomprehensible sounds, and 2 for decerebrate posturing. Adding these together (1 for eye opening + 2 for verbal + 2 for motor) results in a total of 5. This score reflects the severe impairment of consciousness and indicates the need for urgent medical evaluation and intervention.