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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View Related questions
Correct Answer is C
Explanation
A) Move client to a double room. Placing the client in a double room may increase the risk of wandering and confusion, especially if the other occupant has different routines or behaviors. A single room can provide a more controlled and familiar environment, which may help reduce anxiety and the tendency to wander.
B) Encourage participation in activities that provide excessive stimulation. While engagement in activities is beneficial for clients with dementia, providing excessive stimulation can lead to increased confusion and agitation. Activities should be tailored to the client's abilities and interests, promoting engagement without overwhelming them.
C) Use a bed alarm. Implementing a bed alarm is an effective safety measure for clients who wander. It helps alert staff when the client attempts to get out of bed, allowing for timely intervention to prevent wandering and potential injury. This proactive approach supports the client's safety while maintaining their dignity.
D) Use chemical restraints at bedtime. The use of chemical restraints is generally discouraged in managing clients with dementia due to ethical concerns and potential side effects. Alternatives such as environmental modifications and non-pharmacological interventions should be prioritized to ensure the client’s safety and comfort without resorting to medication.
Correct Answer is D
Explanation
A) Diuretic: Diuretics are not typically indicated following an ischemic stroke unless there are specific comorbid conditions, such as heart failure or hypertension, that warrant their use. They do not address the primary needs of stroke management.
B) Anticonvulsant: While some stroke patients may require anticonvulsants if they experience seizures, this is not a standard therapy for all ischemic stroke patients upon discharge. The primary focus after an ischemic stroke is often on preventing future strokes rather than seizure control.
C) Opioid analgesic: Opioids are generally not indicated for stroke management and are not a standard part of discharge therapy. Pain management is important, but other medications are prioritized for stroke prevention and rehabilitation.
D) Antithrombotic: Antithrombotic therapy, which includes antiplatelet agents (like aspirin) or anticoagulants, is crucial for preventing further ischemic events. This type of pharmacologic therapy is typically prescribed for patients post-ischemic stroke to reduce the risk of subsequent strokes.