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) 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.
Correct Answer is A
Explanation
A) Discard samples that contain urine: This is the correct action. Urine can contaminate the fecal sample and lead to false-positive results. Ensuring that the sample is free from urine is essential for accurate testing.
B) Take the sample from the outer edge of formed stool: While it is important to collect from a clean area, the preferred method is to take samples from different areas of the stool, not just the outer edge, to ensure representative testing.
C) Wear sterile gloves when collecting the sample: While wearing gloves is important for infection control, non-sterile gloves are typically sufficient for this type of procedure. The focus should be on avoiding contamination of the sample rather than sterility.
D) Collect three samples from a single bowel movement: This statement is incorrect; the standard practice is to collect samples from three different bowel movements on different days, rather than multiple samples from a single event, to increase the reliability of the test results.