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) Elevation in blood pressure: An elevation in blood pressure is not an indicator of the effectiveness of furosemide. In fact, effective diuresis would typically lead to a reduction in blood pressure, especially in cases of pulmonary edema related to heart failure.
B) Respiratory rate of 24/min: A respiratory rate of 24/min indicates tachypnea, which is often associated with respiratory distress or ongoing pulmonary congestion. This finding does not suggest that the furosemide is effective; instead, it may indicate that further intervention is needed.
C) Adventitious breath sounds: The presence of adventitious breath sounds, such as wheezing or crackles, suggests ongoing fluid accumulation in the lungs and is not an indicator of effective diuresis. Effective treatment should lead to clearer breath sounds as fluid is removed.
D) Weight loss of 1.8 kg (4 lb) in the past 24 hr: This finding is a strong indicator of the effectiveness of furosemide. A significant weight loss, especially in a client with pulmonary edema, reflects a reduction in fluid overload. Since furosemide works by promoting diuresis, this weight loss suggests that the medication is effectively reducing excess fluid in the body.
Correct Answer is C
Explanation
A) Remind the client of the importance of medication adherence.: While emphasizing medication adherence is important, it does not directly advocate for the client's needs related to self-care at home. It is more of a standard teaching point rather than a specific action to support the client's independence.
B) Tell the client to avoid places where there are large crowds of people.: Advising the client to avoid crowded places is a precaution to prevent infection, but it does not empower the client or help them maintain their self-care abilities. Advocacy involves supporting the client's choices and helping them navigate their circumstances.
C) Initiate a referral for the client to a home health agency.: This action demonstrates client advocacy by actively seeking resources that can provide the client with the support they need to manage their care at home. A home health agency can offer assistance with medication management, monitoring health status, and providing companionship, which aligns with the client's goal of self-care while living alone.
D) Instruct the client to avoid eating raw vegetables.: While this is a valid dietary recommendation for someone with a compromised immune system, it does not specifically advocate for the client’s self-care or independence. It is a preventive measure rather than a supportive action that empowers the client.