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) Serosanguineous drainage: While serosanguineous drainage can be expected after surgery, it is typically not alarming unless it significantly increases or changes in character. This finding alone does not indicate an immediate complication that requires urgent attention, making it a lower priority to report compared to other findings.
B) Client report of incisional pain: Postoperative pain is common and expected after a complete thyroidectomy. While the nurse should assess and manage the pain appropriately, this symptom is not unusual and does not signal a critical issue that would necessitate immediate reporting to the healthcare provider.
C) Client report of nausea: Nausea can occur after surgery due to anesthesia or medications. Although it should be addressed and managed, it is not a life-threatening complication. Therefore, this finding does not take priority over other more concerning symptoms.
D) Muscle twitching: Muscle twitching in a postoperative thyroidectomy patient may indicate hypocalcemia, a possible complication due to potential damage to the parathyroid glands during surgery. This condition can lead to severe complications if not addressed promptly, including tetany or seizures. Given the potential seriousness of this finding, it is critical for the nurse to report it to the healthcare provider immediately to ensure appropriate evaluation and intervention.
Correct Answer is A
Explanation
A) Remove one of the weights: This is the appropriate action. If the weights are resting on the floor, it indicates that the traction is ineffective, and removing one weight may be necessary to restore proper traction. However, the nurse should first verify the prescribed amount of weight with the healthcare provider before making adjustments.
B) Pull the client up in bed: While it may be necessary to reposition the client, pulling them up in bed does not address the issue of the weights resting on the floor and could potentially cause discomfort or injury.
C) Increase the elevation of the affected extremity: While elevating the extremity may be beneficial for swelling or comfort, it does not resolve the issue of ineffective traction caused by the weights on the floor.
D) Tie knots in the ropes near the pulleys to shorten them: This action is inappropriate. Tying knots in the ropes could interfere with the proper function of the traction system and is not a safe or effective solution to the problem.