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) "Clean the spacer daily with cold water": While it is important to clean the spacer regularly to prevent bacterial growth, the recommendation is usually to clean it weekly with warm, soapy water rather than daily with cold water. This detail is essential for effective use but not the most critical point during initial teaching.
B) "Hold your breath for 10 seconds once you inhale": This statement is key to ensuring effective medication delivery. Holding the breath for about 10 seconds allows the medication to settle in the lungs, maximizing its therapeutic effects. This information is crucial for the client to understand the proper technique for using the inhaler with a spacer.
C) "Wait 30 seconds between puffs": While it is advisable to wait for a brief period between puffs to allow the first dose to be effective, the recommended wait time is generally around 1 minute, particularly if using a different medication or if instructed by the healthcare provider. Therefore, stating 30 seconds may be misleading.
D) "The spacer should make a whistling sound as you inhale": A whistling sound during inhalation may indicate that the spacer is being used incorrectly or that the client is inhaling too forcefully. The absence of a whistling sound is often a sign of proper technique. Therefore, this statement is misleading and not appropriate teaching for effective inhaler use.
Correct Answer is D
Explanation
A) Serosanguineous drainage: While serosanguineous drainage can be expected after surgery, it is typically not alarming unless it significantly increases or changes in character. This finding alone does not indicate an immediate complication that requires urgent attention, making it a lower priority to report compared to other findings.
B) Client report of incisional pain: Postoperative pain is common and expected after a complete thyroidectomy. While the nurse should assess and manage the pain appropriately, this symptom is not unusual and does not signal a critical issue that would necessitate immediate reporting to the healthcare provider.
C) Client report of nausea: Nausea can occur after surgery due to anesthesia or medications. Although it should be addressed and managed, it is not a life-threatening complication. Therefore, this finding does not take priority over other more concerning symptoms.
D) Muscle twitching: Muscle twitching in a postoperative thyroidectomy patient may indicate hypocalcemia, a possible complication due to potential damage to the parathyroid glands during surgery. This condition can lead to severe complications if not addressed promptly, including tetany or seizures. Given the potential seriousness of this finding, it is critical for the nurse to report it to the healthcare provider immediately to ensure appropriate evaluation and intervention.