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) Administer an oral opioid for breakthrough pain: While breakthrough pain can occur, using an oral opioid in conjunction with a PCA device is generally not recommended without specific guidance from a healthcare provider. The PCA device is designed to provide continuous pain relief, and adding another opioid could increase the risk of overdose or respiratory depression.
B) Encourage family members to press the PCA button for the client: Family members should not press the PCA button for the client. PCA is meant for self-administration, allowing patients to control their pain relief within prescribed limits. Allowing others to administer the medication could lead to accidental overdosing and potential respiratory depression.
C) Monitor the client's respiratory status every 4 hr: While monitoring respiratory status is crucial, doing so every 4 hours may not be sufficient, especially right after initiating or adjusting PCA therapy. Respiratory status should be monitored more frequently (e.g., every 1 to 2 hours) in the initial phases to catch any signs of respiratory depression early.
D) Teach the client how to self-medicate using the PCA device: This is the most appropriate action. Educating the client about how to use the PCA device empowers them to manage their pain effectively. Understanding the operation, such as the lockout feature and when they can safely press the button, is vital for ensuring effective pain control while minimizing the risk of overdose.
Correct Answer is A
Explanation
A) Slow infusion rate and contact the provider: The client is exhibiting signs of fluid overload, as evidenced by dyspnea and a relatively high blood pressure, along with a significant positive fluid balance (960 mL intake versus 300 mL output). Slowing the infusion rate allows for better management of fluid status, while contacting the provider is crucial to reassess the treatment plan and address potential complications.
B) Change infusion to lactated Ringer's and maintain rate: This action is inappropriate because the underlying issue appears to be fluid overload rather than the type of fluid being administered. Changing the infusion to a different type of fluid does not address the need to manage the current fluid overload situation.
C) Administer prescribed corticosteroids: While corticosteroids may be indicated for certain conditions, in this scenario, the priority is addressing the client's immediate signs of fluid overload rather than administering corticosteroids without further assessment.
D) Lower the head of the bed to semi-Fowler's: While positioning the client to promote comfort and ease breathing is important, the more critical intervention is to address the infusion rate and contact the provider regarding the client’s deteriorating condition. Lowering the head of the bed does not address the underlying problem of fluid overload.