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 B
Explanation
A) Check pressure points every 12 hr.: This action is insufficient frequency for a client in skeletal traction. Pressure points should be assessed more frequently, ideally every 2 hours, to prevent skin breakdown and complications related to immobility.
B) Provide the client with a trapeze bar.: This is the most appropriate action. A trapeze bar allows the client to assist with repositioning themselves and helps to reduce strain on the muscles and joints, promoting better mobility while in traction.
C) Instruct the client to use their elbows to reposition.: While this might help the client move slightly, using the elbows alone could lead to strain and discomfort. Proper use of a trapeze bar is a better approach to support safe and effective repositioning.
D) Remove the weights before changing the client's bed linens.: Weights should never be removed without a healthcare provider's order as this can disrupt the alignment and effectiveness of the skeletal traction, potentially causing complications.
Correct Answer is D
Explanation
A) Acute loss of alveolar elasticity: While loss of alveolar elasticity can impact overall lung function, it is more associated with chronic conditions like emphysema rather than acute asthma attacks. In asthma, the primary issue is related to airway obstruction and inflammation rather than alveolar elasticity.
B) Decreased responsiveness of airways to allergens: During an acute asthma attack, the airways typically exhibit increased sensitivity and responsiveness to allergens and irritants, not decreased responsiveness. This heightened response contributes to the bronchoconstriction and inflammation seen in asthma.
C) Suppressed bronchiolar inflammatory response: In an asthma attack, there is actually an exaggerated inflammatory response in the bronchioles. This inflammation leads to swelling, mucus production, and bronchoconstriction, which contribute to the difficulty in breathing.
D) Inability to exhale retained carbon dioxide: This is a significant factor during an acute asthma attack. The bronchoconstriction and airway obstruction make it difficult for the client to exhale fully, leading to the retention of carbon dioxide. This can cause respiratory acidosis and worsen the client's condition, highlighting the urgency of treatment.