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 C
Explanation
A) Generalized abdominal pain: While abdominal pain can occur with peritonitis, it is not always the earliest indication. Pain may develop after other symptoms become apparent, making it less specific as an initial sign.
B) Fever: Fever is a common symptom of infection, including peritonitis. However, it can also occur in various other conditions and may not be the first noticeable symptom, especially if the infection is localized.
C) Cloudy effluent: Cloudy or turbid dialysate effluent is often the earliest and most specific indication of peritonitis in patients undergoing peritoneal dialysis. This change in the appearance of the effluent suggests an infection, and the presence of cloudy fluid should prompt further evaluation for peritonitis.
D) Increased heart rate: An increased heart rate can be a response to various conditions, including infection, but it is not specific to peritonitis and may not be the earliest sign.
Correct Answer is D
Explanation
A) "I should use both hands to recap a needle." This statement reflects unsafe practice. The correct method is to avoid recapping needles whenever possible, and if it is necessary, to use a one-handed technique to minimize the risk of a needlestick injury.
B) "Sterile gloves are required when administering an IM injection." This statement is incorrect because sterile gloves are not typically required for intramuscular (IM) injections. Clean gloves are sufficient, as the injection site does not require a sterile field unless there is a specific reason, such as a compromised immune system.
C) "I should wear a gown to remove linens from a client's bed." While wearing a gown may be necessary in certain situations (such as when there is a risk of exposure to blood or body fluids), it is not universally required for simply removing linens. The decision to wear a gown should be based on the assessment of the risk involved.
D) "I should wear goggles when irrigating a wound." This statement demonstrates an understanding of personal protective equipment use. Goggles or face shields are recommended to protect the eyes from potential splashes of blood or other body fluids during wound irrigation, which is a procedure that can pose a risk of exposure.