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) 150 mL of serosanguineous drainage indicates a mixture of serum and blood, which can be expected in the immediate postoperative period. While it should be monitored, this amount is generally not alarming and typically does not require immediate reporting to the provider unless there are other concerning signs.
B) 200 mL of brown drainage may indicate the presence of old blood or bile, depending on the source. While this could warrant further assessment, it is not an immediate cause for concern in the first hour post-surgery, especially if the client is stable and has no other symptoms.
C) 100 mL of red drainage is concerning because bright red blood can indicate active bleeding. This finding is particularly alarming in the first postoperative hour, as it suggests that there may be a significant complication such as a hemorrhage or disruption of the surgical site. Immediate reporting to the provider is necessary to assess the need for intervention.
D) 75 mL of greenish-yellow drainage likely indicates bile or gastric contents. While it should be monitored, especially in the context of the type of surgery performed, this amount alone does not typically necessitate immediate reporting to the provider unless accompanied by other abnormal signs or symptoms.
Correct Answer is C
Explanation
A) Blistering at the site: Blistering is typically associated with partial-thickness burns rather than full-thickness burns. Full-thickness burns destroy both the epidermis and dermis, which usually do not present with blisters.
B) Epithelialization at the site: Epithelialization is a healing process that occurs after the burn site begins to heal. Since this client has sustained major full-thickness burns only 12 hours ago, epithelialization is not expected at this early stage.
C) Edema at the site: Edema is expected in the early stages following a major burn injury due to the inflammatory response and fluid shift that occurs. This finding aligns with the body's response to trauma and is common within the first 24 hours after a burn.
D) Severe pain at the site: Full-thickness burns typically have less pain at the site compared to partial-thickness burns because the nerve endings in the skin are destroyed. While there may be pain in surrounding areas or in partial-thickness areas, the full-thickness burn itself is often painless.