A client is experiencing a thyroid storm precipitated by a right lower lobe pneumonia. The vital signs are: HR-140/min; RR-28, B/P-196/54; T-101.4°F, Pulse Oximetry-96%. What action should the nurse take?

Prepare for endotracheal intubation and ventilatory support.

Provide continuous sedation for pain relief.

Initiate cardiac monitoring and assess for reflex bradycardia.

Maintain IV fluid infusion and assess adequacy of hydration.

Answer and Explanation

The Correct Answer is D

hoice A reason: Preparing for endotracheal intubation and ventilatory support is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with respiratory failure or impending airway obstruction, which are not the case for this client.

Choice B reason: Providing continuous sedation for pain relief is not the action that the nurse should take for a client with thyroid storm. This intervention may worsen the client's condition by suppressing the respiratory drive and lowering the blood pressure. The nurse should administer antithyroid medications, beta blockers, and corticosteroids as prescribed to reduce the thyroid hormone levels and the associated symptoms.

Choice C reason: Initiating cardiac monitoring and assessing for reflex bradycardia is not the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with hyperkalemia or digoxin toxicity, which are not the case for this client. The nurse should monitor the client's heart rate and rhythm, but not expect a reflex bradycardia, which is a paradoxical slowing of the heart rate in response to a rapid rise in blood pressure.

Choice D reason: Maintaining IV fluid infusion and assessing adequacy of hydration is the action that the nurse should take for a client with thyroid storm. This intervention is indicated for clients with thyroid storm, as they are at risk of dehydration and electrolyte imbalance due to increased metabolic rate, fever, sweating, vomiting, and diarrhea. The nurse should administer isotonic fluids, such as normal saline, and monitor the client's fluid intake and output, urine specific gravity, and serum electrolytes.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","C"]

Explanation

Choice A: Elevated troponins. This is a correct answer. Troponins are proteins that regulate the myocardial contractile process². They are released into the bloodstream when the myocardial cells are damaged by ischemia or infarction². Troponins are highly specific and sensitive indicators of myocardial injury². The normal range for troponin I is less than 0.03 ng/mL and for troponin T is less than 0.01 ng/mL².

Choice B: Decreased homocysteine levels. This is not a correct answer. Homocysteine is an amino acid that is involved in the metabolism of methionine². Elevated homocysteine levels are associated with an increased risk of cardiovascular disease, but they are not a direct marker of myocardial injury². The normal range for homocysteine is 5 to 15 micromol/L².

Choice C: Elevated CK-MB. This is a correct answer. CK-MB is one of the isoenzymes of creatine kinase, an enzyme that catalyzes the conversion of creatine to phosphocreatine, which is used for energy storage in the muscles². CK-MB is found mainly in the myocardium and is released into the blood when the myocardial cells are injured². CK-MB is a specific and sensitive marker of myocardial injury, but it is less specific than troponins². The normal range for CK-MB is 0 to 3 ng/mL².

Choice D: Decreased alkaline phosphatase (ALP).This is not a correct answer. ALP is an enzyme that is found in various tissues, such as the liver, bone, intestine, and placenta². ALP is not a marker of myocardial injury, and its levels are not affected by ischemia or infarction². The normal range for ALP is 30 to 120 U/L².

Choice E: Increased platelet count.This is not a correct answer. Platelets are blood cells that are involved in hemostasis and clot formation². Increased platelet count, or thrombocytosis, can be a sign of inflammation, infection, malignancy, or other conditions². Platelet count is not a marker of myocardial injury, and it does not reflect the extent of ischemia or infarction². The normal range for platelet count is 150,000 to 450,000 per microliter of blood².

A. Fried chicken, baked beans, French fries, and cake B. Tomato soup, fried flounder, white rice, and a grapefruit C. Barbecue pulled pork sandwich, fresh green beans, mashed potatoes, and ice cream D. Baked tuna, fresh broccoli, brown rice, and fresh cantaloupe

Correct Answer is D

Explanation

Choice A reason: This is a high-fat, high-sodium, and high-calorie meal that is not suitable for a client with hypertension. Fried foods, processed meats, and baked beans are sources of saturated fat and sodium that can raise blood pressure and cholesterol levels. Cake is a source of added sugar that can contribute to obesity and diabetes.

Choice B reason: This is a moderate-fat, moderate-sodium, and moderate-calorie meal that is not ideal for a client with hypertension. Fried flounder and tomato soup are sources of fat and sodium that can increase blood pressure. White rice is a refined carbohydrate that can spike blood sugar levels and increase the risk of diabetes.

Choice C reason: This is a high-fat, high-sodium, and high-calorie meal that is not appropriate for a client with hypertension. Barbecue pulled pork sandwich, mashed potatoes, and ice cream are sources of saturated fat and sodium that can elevate blood pressure and cholesterol levels. Fresh green beans are the only healthy component of this meal.

Choice D reason: This is a low-fat, low-sodium, and low-calorie meal that is suitable for a client with hypertension. Baked tuna, fresh broccoli, brown rice, and fresh cantaloupe are sources of lean protein, fiber, complex carbohydrates, vitamins, minerals, and antioxidants that can lower blood pressure and cholesterol levels, prevent obesity and diabetes, and promote cardiovascular health.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client is experiencing a thyroid storm precipitated by a right lower lobe pneumonia. The vital signs are: HR-140/min; RR-28, B/P-196/54; T-101.4°F, Pulse Oximetry-96%. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the chart of a client with an indication of myocardial infarction or unstable angina. Which laboratory test result(s) should the nurse recognize as an indication of myocardial injury? (Select all that apply)

Correct Answer is ["A","C"]

Explanation

The nurse is assisting a client diagnosed with hypertension with menu selection. Which items should the nurse suggest?

Correct Answer is D

Explanation

The nurse is reviewing the laboratory data of a client diagnosed with coronary artery disease. Which set of laboratory results indicates a need for client teaching regarding dietary modifications?

The client says to the nurse, "I get a headache every time I put on my Nitropatch." Which response by the nurse would be most appropriate?

The nurse should monitor the client for clinical manifestations of digoxin toxicity if the laboratory report reflects a serum:

The nurse should teach the client who is taking digoxin 0.125 mg PO daily to call the healthcare provider if which side effect is experienced?

The nurse has obtained assessment data for a client who is scheduled for a cardiac angiogram (catheterization). Which information must the nurse report to the health care provider prior to the procedure?

The nurse is reviewing the laboratory test results of a client with long-standing hypertension. Which result would be of most concern to the nurse?

Which statement, made by the client with coronary artery disease, alerts the nurse that the client may be experiencing difficulty adapting to the illness?

The nurse recognizes that which diagnostic test is used to detect the most common cause of chronic iron deficiency anemia?