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
Explanation
A) Check the pulse distal to the graft: This action is crucial for assessing the patency of the arteriovenous graft. Monitoring the pulse distal to the graft ensures adequate blood flow and helps detect any complications such as thrombosis or compromised circulation.
B) Keep the left forearm below the level of the heart: Keeping the forearm below heart level is not necessary and could potentially compromise circulation. The limb should be elevated as tolerated to reduce swelling and promote healing.
C) Collect blood specimens from the graft: Collecting blood specimens from the graft site is not appropriate, as it can increase the risk of infection and damage to the graft. Blood samples should typically be drawn from another site.
D) Splint the left forearm to prevent damage to the graft: While protecting the graft site is important, splinting is generally not required unless specifically ordered for a particular reason. The focus should be on gentle use and monitoring rather than immobilization.
Correct Answer is A
Explanation
A) Negative sputum cultures for acid-fast bacillus: This is the primary indicator that a client with pulmonary tuberculosis is no longer infectious. Once the sputum cultures are negative for acid-fast bacilli on two consecutive tests, the client is considered to have a reduced risk of transmitting the infection to others.
B) Mantoux skin test revealing an induration of less than 1 mm: A negative Mantoux test (induration of less than 5 mm) indicates that the person has not been exposed to TB or does not have an active infection. However, this test is not used to determine infectiousness and may not be relevant for someone already diagnosed with TB.
C) Client no longer coughing up blood-tinged sputum: While the absence of blood-tinged sputum may indicate improvement, it does not necessarily mean the client is no longer infectious. Infectiousness is more accurately assessed through sputum cultures.
D) Positive Quantiferon-TB Gold test (negative): The Quantiferon-TB Gold test is a blood test that can indicate TB infection but does not determine whether the client is infectious. A positive result can occur even when a client is being effectively treated for tuberculosis.