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 B
Explanation
A)"Iwilltrytolimitfoodsthatcontainsalt.":Limitingsaltintakeisimportantformanagingheartfailurebutdoesn'tspecificallyaddresstheadverseeffectsoffurosemide.Thisdiureticcancauseelectrolyteimbalances,butsaltrestrictionismorerelatedtooverallheartfailuremanagement.
B)"I'mgoingtoincludemorecantaloupeinmydiet.":Furosemidecancausepotassiumdepletion,andcantaloupeishighinpotassium.Increasingpotassium-richfoodsinthediethelpscounteractthisadverseeffect,indicatingtheclientunderstandstheneedtomaintainelectrolytebalance.
C)"IwillcheckmypulsebeforeItakethemedication.":Whilemonitoringheartratecanbeusefulinmanagingheartconditions,itisnotspecifictotheprimaryadverseeffectsoffurosemide.Thekeyconcernwiththismedicationisitsimpactonelectrolytesandfluidbalance.
D)"I'llcheckmybloodpressuresoitdoesn'tgettoohigh.":Furosemidetypicallylowersbloodpressure,sotheconcernwouldbehypotension(lowbloodpressure)ratherthanhypertension(highbloodpressure).Thisstatementdoesn’treflectanunderstandingoffurosemide’sprimaryadverseeffects.
Correct Answer is C
Explanation
A) The client moves the cane 2 feet ahead.: Moving the cane 2 feet ahead is not appropriate, as the cane should be positioned close to the body to provide support. The cane is typically moved just ahead of the weaker leg to help with balance and support.
B) The client takes a step with their right foot first.: This action does not align with the recommended method for using a quad cane with left-sided weakness. The correct technique involves moving the cane and the weaker leg together, which helps maintain balance.
C) The client holds the cane with their left hand.: This action demonstrates an understanding of how to use a quad cane effectively. Holding the cane with the stronger hand (the right hand in this case) is generally recommended, but if the client has left-sided weakness and needs to use the cane for stability, they would typically hold it with their left hand to maintain balance while stepping with the right leg.
D) The client advances the weaker leg forward to the cane.: This action indicates a misunderstanding. The correct method involves advancing the cane first, followed by the weaker leg, to ensure proper support and balance.