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) Avoid administering IV pain medication: While caution is warranted when administering IV medications to a client with petechiae, particularly if thrombocytopenia is suspected, avoiding pain management is not the appropriate action. Pain relief is crucial for the client’s comfort, and IV medications can be safely administered with proper precautions.
B) Determine the client's blood type: Knowing the client's blood type is important for transfusion purposes, especially if there is significant bleeding. However, this action is not the immediate priority in response to the observation of petechiae. The presence of petechiae is more directly related to bleeding risk rather than blood type.
C) Implement airborne precautions: Airborne precautions are necessary for certain infections (e.g., tuberculosis), but they are not indicated for the management of petechiae related to chronic lymphocytic leukemia. The presence of petechiae does not suggest an airborne infection; thus, this action does not address the immediate concern.
D) Institute bleeding precautions: Petechiae indicate a potential for bleeding due to thrombocytopenia, which is common in clients with chronic lymphocytic leukemia. Instituting bleeding precautions, such as using a soft toothbrush, avoiding invasive procedures, and monitoring for additional signs of bleeding, is crucial to prevent serious complications. Therefore, this action is the most appropriate and immediate response.
Correct Answer is D
Explanation
A) Heart rate 60/min: A heart rate of 60 beats per minute is on the lower end of the normal range. While bradycardia can be concerning, it does not indicate the need for an increase in dopamine dosage specifically. The primary goal of dopamine administration in hypovolemic shock is to improve perfusion and blood pressure, rather than solely addressing heart rate.
B) Respiratory rate 14/min: A respiratory rate of 14 breaths per minute is within the normal range for adults. This finding suggests that the client is not experiencing respiratory distress and does not warrant an increase in the dopamine dosage. The focus should be on hemodynamic parameters rather than respiratory rate in this context.
C) Oxygen saturation 95%: An oxygen saturation of 95% is considered acceptable and indicates adequate oxygenation. While maintaining oxygen saturation is important, this finding does not directly reflect the effectiveness of dopamine in improving hemodynamics. Therefore, it does not indicate the need for a dosage increase.
D) Blood pressure 90/50 mm Hg: A blood pressure reading of 90/50 mm Hg indicates hypotension and poor perfusion, which is a significant concern in a client with hypovolemic shock. An increase in dopamine dosage is warranted in this situation, as dopamine is administered to enhance cardiac output and improve blood pressure. Therefore, this finding strongly indicates the need to adjust the medication to ensure adequate hemodynamic support.