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 D
Explanation
A) Acute loss of alveolar elasticity: While loss of alveolar elasticity can impact overall lung function, it is more associated with chronic conditions like emphysema rather than acute asthma attacks. In asthma, the primary issue is related to airway obstruction and inflammation rather than alveolar elasticity.
B) Decreased responsiveness of airways to allergens: During an acute asthma attack, the airways typically exhibit increased sensitivity and responsiveness to allergens and irritants, not decreased responsiveness. This heightened response contributes to the bronchoconstriction and inflammation seen in asthma.
C) Suppressed bronchiolar inflammatory response: In an asthma attack, there is actually an exaggerated inflammatory response in the bronchioles. This inflammation leads to swelling, mucus production, and bronchoconstriction, which contribute to the difficulty in breathing.
D) Inability to exhale retained carbon dioxide: This is a significant factor during an acute asthma attack. The bronchoconstriction and airway obstruction make it difficult for the client to exhale fully, leading to the retention of carbon dioxide. This can cause respiratory acidosis and worsen the client's condition, highlighting the urgency of treatment.
Correct Answer is B
Explanation
A) Fever: While fever can occur in various allergic reactions, it is not a specific indicator of anaphylaxis. It may signal an infection or other inflammatory process rather than an immediate hypersensitivity reaction.
B) Laryngeal edema: This is a hallmark sign of anaphylaxis. It indicates swelling in the throat that can compromise the airway, making it a critical and life-threatening response. Immediate recognition and intervention are necessary to ensure the client's airway remains patent.
C) Hypertension: Although anaphylaxis can sometimes lead to hypotension due to vascular collapse, hypertension is not typically a sign of anaphylaxis. Instead, hypotension is more commonly associated with severe allergic reactions.
D) Arrhythmia: While arrhythmias can occur due to various causes, including stress or electrolyte imbalances, they are not a direct indicator of anaphylaxis. Anaphylaxis primarily presents with respiratory symptoms, skin reactions, and gastrointestinal symptoms, rather than primarily affecting heart rhythm.