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 C
Explanation
A) Administer oxygen at 2 L/min: While oxygen therapy is often necessary for clients with emphysema, it should be titrated based on arterial blood gas (ABG) results and individual needs. Administering oxygen without proper assessment can lead to respiratory depression in some clients due to their reliance on hypoxic drive.
B) Encourage use of incentive spirometry for 5 min every 2 hr: Incentive spirometry is beneficial for preventing atelectasis and improving lung expansion; however, clients with emphysema may not tolerate it well due to airflow limitation. Focus should be on techniques that facilitate breathing rather than forced inhalation.
C) Teach the client a breathing exercise with a longer inhalation phase: This intervention is appropriate as it helps optimize lung function by promoting more effective gas exchange. Teaching techniques like pursed-lip breathing can help extend the exhalation phase, reducing air trapping and improving oxygenation.
D) Limit fluid intake to 1,000 mL per day: Hydration is essential for clients with emphysema to help thin secretions. Limiting fluid intake can lead to dehydration and increased viscosity of mucus, complicating respiratory efforts.
Correct Answer is B
Explanation
A) Cheyne-Stokes respirations: This pattern of breathing can indicate severe neurological impairment but typically arises after other signs of increased intracranial pressure (ICP) have emerged. It is more associated with significant brain dysfunction.
B) Altered level of consciousness: This is often the first sign of deteriorating neurological status in clients with increased ICP. Changes in consciousness can range from confusion and disorientation to lethargy or coma. Monitoring for these subtle shifts is crucial for early intervention.
C) Decorticate posturing: This is a sign of severe brain injury and indicates a significant level of impairment. However, it usually appears after alterations in consciousness and is not the initial sign.
D) Pupillary dilation: While changes in pupil size and reactivity are important indicators of neurological status, they often occur after a decline in consciousness. Altered consciousness typically precedes these changes.