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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View Related questions
Correct Answer is A
Explanation
A) Gently elevate the client's head and note any nuchal rigidity: This action is crucial for assessing for meningeal irritation, which is a common sign of bacterial meningitis. Nuchal rigidity refers to stiffness in the neck that makes it difficult for the client to flex their neck forward. This sign, along with other symptoms, can help confirm the suspicion of meningitis.
B) Strike the client's patellar tendon with a percussion hammer and note any increase in response: While assessing deep tendon reflexes can provide information about neurological function, it is not specific to meningitis. Increased reflex response may not
directly indicate meningeal irritation.
C) Tap the client's facial nerve and note any facial twitching: This action is not a standard assessment for bacterial meningitis. Facial twitching could indicate other neurological issues but is not specifically related to meningitis.
D) Run a tongue blade on the outside of the client's sole and note any flaring of the toes: This action describes the Babinski reflex, which is not a typical assessment for meningitis. It may indicate upper motor neuron lesions but does not specifically assess for meningitis.
Correct Answer is D
Explanation
A) "I will increase my intake of canned vegetables.": This statement indicates a lack of understanding. Canned vegetables can be high in sodium, which is not advisable for individuals with cardiovascular disease. Fresh or frozen vegetables are usually better options.
B) "I will drink whole milk with my cereal.": Whole milk is higher in saturated fat and cholesterol, which can contribute to cardiovascular issues. Low-fat or non-fat milk would be a more appropriate choice for someone with cardiovascular disease.
C) "I will limit my portions of meat to 8 ounces.": While portion control is important, this statement does not reflect an understanding of the type of meat to consume. It’s not just about the portion size but also about choosing lean meats and limiting red and processed meats.
D) "I will use canola oil when making salad dressing.": This statement shows an understanding of dietary recommendations for cardiovascular health. Canola oil is a healthier choice due to its lower saturated fat content and higher levels of heart-healthy monounsaturated fats, making it a better option for someone managing cardiovascular disease.