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) Cheyne-Stokes respirations: This pattern of breathing can indicate severe neurological impairment but typically arises after other signs of increased intracranial pressure (ICP) have emerged. It is more associated with significant brain dysfunction.
B) Altered level of consciousness: This is often the first sign of deteriorating neurological status in clients with increased ICP. Changes in consciousness can range from confusion and disorientation to lethargy or coma. Monitoring for these subtle shifts is crucial for early intervention.
C) Decorticate posturing: This is a sign of severe brain injury and indicates a significant level of impairment. However, it usually appears after alterations in consciousness and is not the initial sign.
D) Pupillary dilation: While changes in pupil size and reactivity are important indicators of neurological status, they often occur after a decline in consciousness. Altered consciousness typically precedes these changes.
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.