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) Administer an oral opioid for breakthrough pain: While breakthrough pain can occur, using an oral opioid in conjunction with a PCA device is generally not recommended without specific guidance from a healthcare provider. The PCA device is designed to provide continuous pain relief, and adding another opioid could increase the risk of overdose or respiratory depression.
B) Encourage family members to press the PCA button for the client: Family members should not press the PCA button for the client. PCA is meant for self-administration, allowing patients to control their pain relief within prescribed limits. Allowing others to administer the medication could lead to accidental overdosing and potential respiratory depression.
C) Monitor the client's respiratory status every 4 hr: While monitoring respiratory status is crucial, doing so every 4 hours may not be sufficient, especially right after initiating or adjusting PCA therapy. Respiratory status should be monitored more frequently (e.g., every 1 to 2 hours) in the initial phases to catch any signs of respiratory depression early.
D) Teach the client how to self-medicate using the PCA device: This is the most appropriate action. Educating the client about how to use the PCA device empowers them to manage their pain effectively. Understanding the operation, such as the lockout feature and when they can safely press the button, is vital for ensuring effective pain control while minimizing the risk of overdose.
Correct Answer is D
Explanation
A) Pain level: While assessing pain is important, it is not the immediate priority in the post-anesthesia care unit (PACU). Pain management can be addressed once the client's vital signs and respiratory status are stable.
B) Surgical site: Evaluating the surgical site is necessary to check for complications such as bleeding or infection, but it comes after ensuring the client’s vital functions, particularly their breathing, are stable.
C) Level of consciousness: Assessing the level of consciousness is essential for determining neurological status. However, it is secondary to ensuring the airway and breathing are adequate, as these are critical for survival.
D) Respiratory status: This is the priority assessment in the PACU. Following anesthesia, clients are at significant risk for respiratory complications, including hypoventilation or airway obstruction. Ensuring that the client is breathing adequately and that their airway is clear is the most critical assessment for immediate safety.