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) 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 B
Explanation
A) Alert the emergency response team: While alerting the team is important, it should not be the first action taken. Immediate care to protect the client’s integrity is the priority before involving additional personnel.
B) Cover the area with sterile normal saline-soaked gauze: This is the most immediate and critical action. Covering the exposed bowel with sterile saline-soaked gauze helps to prevent infection and keeps the tissue moist, which is essential until surgical intervention can be performed.
C) Place the head of the client's bed at a 15° angle: While positioning the client can help with comfort and possibly reduce further protrusion, it is not the priority action in this emergency situation. The exposed bowel requires immediate protection.
D) Prepare the client for surgery: Preparing for surgery is a necessary step, but it should follow the immediate care for the exposed intestine. Ensuring that the bowel is covered and protected takes precedence.