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 ["A","B","C","D"]
Explanation
A) Place the client in an upright sitting position: This is the first step because it helps to lower blood pressure by promoting venous return and decreasing the effects of increased sympathetic activity associated with autonomic dysreflexia. Immediate positioning can alleviate acute symptoms and prevent further complications.
B) Confirm that the client's bladder is empty: After ensuring the client is positioned appropriately, the next step is to check for urinary retention, which is a common trigger for autonomic dysreflexia. If the bladder is full, it can exacerbate the condition, so emptying it is crucial.
C)Indicate the risk for autonomic dysreflexia in the client's medical record: While this step is important for ongoing patient care and documentation, it is not an immediate priority during an acute episode of autonomic dysreflexia. Documenting the risk should occur after addressing the client's immediate needs to ensure their safety and well-being
D)Administer an antihypertensive medication intravenously: If the client's blood pressure remains elevated after positioning and emptying the bladder, the next step is to provide pharmacological intervention. Administering an antihypertensive medication can help manage and stabilize the client's blood pressure effectively.
Correct Answer is A
Explanation
A) Photophobia: This is a common symptom associated with meningitis. Inflammation of the meninges can lead to sensitivity to light, making photophobia a significant finding during the assessment of a client with meningitis. This symptom can cause discomfort and may lead clients to avoid bright environments.
B) Intermittent headache: While headaches are a common symptom of meningitis, they are typically severe and persistent rather than intermittent. Clients often report a continuous, severe headache that is different from their usual headaches, which is more indicative of meningitis.
C) Petechiae on the chest: Although petechiae can occur in certain types of meningitis, particularly meningococcal meningitis, it is not a universal finding. The presence of petechiae would suggest a more severe systemic involvement, but it is not expected in every case of meningitis.
D) Bradycardia: This is not a typical finding in meningitis. In fact, tachycardia (increased heart rate) is more commonly seen due to fever and infection. Bradycardia might indicate a different underlying issue and is not expected in the context of meningitis.