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 D
Explanation
A) "I've been having problems with bladder control.": While bladder control issues can be associated with certain neurological conditions, they are not specific to myasthenia gravis. This statement may indicate a need for further assessment but does not directly suggest a need for occupational therapy.
B) "I have difficulty swallowing food.": Dysphagia is a common concern in myasthenia gravis, but this statement may warrant a referral to a speech-language pathologist rather than occupational therapy. Addressing swallowing difficulties typically falls within the scope of speech therapy.
C) "I would rather be in a wheelchair than use a walker to get around.": This statement reflects a personal preference for mobility aids. While it could indicate a need for assistance in mobility, it does not specifically point to a need for occupational therapy services.
D) "I have a hard time with brushing my hair.": This statement clearly indicates difficulty with activities of daily living (ADLs) due to muscle weakness associated with myasthenia gravis. A referral for occupational therapy would be appropriate to help the client develop strategies and adaptive techniques to manage daily tasks more effectively.
Correct Answer is C
Explanation
A) Administer aspirin: While administering aspirin is important in the management of acute angina to inhibit platelet aggregation, it is not the immediate priority. Aspirin helps prevent further clot formation but does not relieve the acute symptoms of angina.
B) Initiate IV access: Establishing IV access may be necessary for medication administration, but it should not be the first action taken when a client is experiencing acute angina. Immediate relief of chest pain is the priority.
C) Administer nitroglycerin: This is the first action the nurse should take. Nitroglycerin acts quickly to relieve angina by dilating coronary arteries, thus improving blood flow to the heart muscle. Relief of pain and ischemia is the immediate priority.
D) Measure blood pressure: While monitoring vital signs is crucial, especially in a client with cardiac issues, the most urgent intervention in the context of acute angina is pain relief. Blood pressure may be assessed after administering nitroglycerin since it can affect hemodynamics.