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) Administer aspirin: While administering aspirin is important in the management of acute angina to inhibit platelet aggregation, it is not the immediate priority. Aspirin helps prevent further clot formation but does not relieve the acute symptoms of angina.
B) Initiate IV access: Establishing IV access may be necessary for medication administration, but it should not be the first action taken when a client is experiencing acute angina. Immediate relief of chest pain is the priority.
C) Administer nitroglycerin: This is the first action the nurse should take. Nitroglycerin acts quickly to relieve angina by dilating coronary arteries, thus improving blood flow to the heart muscle. Relief of pain and ischemia is the immediate priority.
D) Measure blood pressure: While monitoring vital signs is crucial, especially in a client with cardiac issues, the most urgent intervention in the context of acute angina is pain relief. Blood pressure may be assessed after administering nitroglycerin since it can affect hemodynamics.
Correct Answer is A
Explanation
A) "Your breathing pattern causes this.": This statement accurately explains the phenomenon known as "tidaling." The rise and fall of fluid in the water-seal chamber is a normal response to the client’s breathing. As the client inhales, the negative pressure in the pleural space increases, causing the fluid level to rise, and it falls during exhalation. This indicates that the chest tube is functioning properly.
B) "This indicates a possible air leak.": An air leak would typically manifest as continuous bubbling in the water-seal chamber, not as tidaling. Tidaling is a normal finding, so this statement is misleading and does not accurately describe the situation.
C) "This means your lung is fully re-expanded.": While tidaling can be a sign of lung re-expansion, it does not definitively indicate that the lung is fully re-expanded. The presence of tidaling alone does not confirm complete re-expansion of the lung.
D) "Suction pressure that is too high causes this.": Suction pressure relates to the amount of suction applied to the drainage system, but it does not cause the normal rise and fall of fluid in the water-seal chamber. This statement is incorrect in the context of explaining the observed phenomenon.