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.

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Correct Answer is C

Explanation

Choice A reason: An early morning headache is not the most common side effect of lisinopril. Lisinopril is a drug that lowers blood pressure and prevents the complications of heart failure. ¹ It belongs to a class of drugs called angiotensin-converting enzyme (ACE) inhibitors, which work by relaxing the blood vessels and reducing the workload of the heart. ¹ Headache is a possible side effect of lisinopril, but it is not very frequent or specific to this drug. ²

Choice B reason: Occasional nausea is not the most common side effect of lisinopril. Lisinopril is a drug that lowers the blood pressure and prevents the complications of heart failure. ¹ It belongs to a class of drugs called angiotensin-converting enzyme (ACE) inhibitors, which work by relaxing the blood vessels and reducing the workload of the heart. ¹ Nausea is a possible side effect of lisinopril, but it is not very frequent or specific to this drug. ²

Choice C reason: A chronic cough is the most common side effect of lisinopril. Lisinopril is a drug that lowers the blood pressure and prevents the complications of heart failure. ¹ It belongs to a class of drugs called angiotensin-converting enzyme (ACE) inhibitors, which work by relaxing the blood vessels and reducing the workload of the heart. ¹ However, ACE inhibitors can also cause a dry, persistent cough that does not go away with time or treatment. ² This cough is due to the accumulation of a substance called bradykinin in the lungs, which irritates the airways and triggers the cough reflex. ³ The cough can be annoying and interfere with the quality of life of the client, but it is not harmful or dangerous. ²

Choice D reason: A dry mouth after eating is not the most common side effect of lisinopril. Lisinopril is a drug that lowers the blood pressure and prevents the complications of heart failure. ¹ It belongs to a class of drugs called angiotensin-converting enzyme (ACE) inhibitors, which work by relaxing the blood vessels and reducing the workload of the heart. ¹ Dry mouth is a possible side effect of lisinopril, but it is not very frequent or specific to this drug. ² Dry mouth can be caused by many factors, such as dehydration, medication, or disease. It can be relieved by drinking water, chewing gum, or using saliva substitutes.

A. Exertional dyspnea resolved B. Heart rate 50 beats/minute C. Heart rhythm regular D. Blood pressure 120/90

Correct Answer is A

Explanation

Choice A reason: Exertional dyspnea is a common symptom of unstable angina, which is caused by reduced blood flow to the heart muscle. Carvedilol is a beta-blocker that reduces the workload of the heart and improves its oxygen supply. Therefore, resolving exertional dyspnea indicates that the medication has been effective.

Choice B reason: A heart rate of 50 beats/minute is not a desired outcome of carvedilol therapy. It may indicate that the dose is too high or that the client has a conduction problem. A normal resting heart rate for adults is between 60 and 100 beats/minute.

Choice C reason: A regular heart rhythm is not a specific indicator of carvedilol effectiveness. Carvedilol can prevent or treat some arrhythmias, but it is not the primary goal of therapy for unstable angina. A regular heart rhythm may also be influenced by other factors such as electrolytes, hydration, and stress.

Choice D reason: A blood pressure of 120/90 is not a sign of carvedilol effectiveness. Carvedilol can lower blood pressure, but it is not the main purpose of treatment for unstable angina. A blood pressure of 120/90 is considered prehypertension, which may increase the risk of cardiovascular complications.

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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 providing medication teaching to a client prescribed lisinopril 10 mg PO daily. Which side effect of the medication will the nurse explain to the client is most common?

Correct Answer is C

Explanation

The nurse is evaluating the effects of the prescribed carvedilol 6.25 mg PO daily for a client with a history of unstable angina. Which of the following reflects that the medication has been effective?

Correct Answer is A

Explanation

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