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) Elevation in blood pressure: An elevation in blood pressure is not an indicator of the effectiveness of furosemide. In fact, effective diuresis would typically lead to a reduction in blood pressure, especially in cases of pulmonary edema related to heart failure.
B) Respiratory rate of 24/min: A respiratory rate of 24/min indicates tachypnea, which is often associated with respiratory distress or ongoing pulmonary congestion. This finding does not suggest that the furosemide is effective; instead, it may indicate that further intervention is needed.
C) Adventitious breath sounds: The presence of adventitious breath sounds, such as wheezing or crackles, suggests ongoing fluid accumulation in the lungs and is not an indicator of effective diuresis. Effective treatment should lead to clearer breath sounds as fluid is removed.
D) Weight loss of 1.8 kg (4 lb) in the past 24 hr: This finding is a strong indicator of the effectiveness of furosemide. A significant weight loss, especially in a client with pulmonary edema, reflects a reduction in fluid overload. Since furosemide works by promoting diuresis, this weight loss suggests that the medication is effectively reducing excess fluid in the body.
Correct Answer is D
Explanation
A) "I should use both hands to recap a needle." This statement reflects unsafe practice. The correct method is to avoid recapping needles whenever possible, and if it is necessary, to use a one-handed technique to minimize the risk of a needlestick injury.
B) "Sterile gloves are required when administering an IM injection." This statement is incorrect because sterile gloves are not typically required for intramuscular (IM) injections. Clean gloves are sufficient, as the injection site does not require a sterile field unless there is a specific reason, such as a compromised immune system.
C) "I should wear a gown to remove linens from a client's bed." While wearing a gown may be necessary in certain situations (such as when there is a risk of exposure to blood or body fluids), it is not universally required for simply removing linens. The decision to wear a gown should be based on the assessment of the risk involved.
D) "I should wear goggles when irrigating a wound." This statement demonstrates an understanding of personal protective equipment use. Goggles or face shields are recommended to protect the eyes from potential splashes of blood or other body fluids during wound irrigation, which is a procedure that can pose a risk of exposure.