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A nurse is caring for a client who has Graves' disease and is experiencing a thyroid storm. Which of the following actions is the nurse's priority?

A.

Provide a cooling blanket.

B.

Monitor the client's cardiac rhythm.

C.

Administer 0.9% sodium chloride IV.

D.

Obtain the client's blood glucose.

Answer and Explanation

The Correct Answer is B

A.    While a cooling blanket may be indicated to reduce fever associated with a thyroid storm, the priority lies in monitoring the cardiac rhythm for potential life-threatening complications such as tachycardia or arrhythmias.
B.    Thyroid storm can precipitate severe cardiac complications, making continuous monitoring of the client's cardiac rhythm imperative to detect any abnormalities promptly.
C.    Administering IV fluids may be necessary to address dehydration, but it is not the priority over monitoring the cardiac rhythm.
D.    While monitoring blood glucose levels is important, it is not the immediate priority in managing a thyroid storm.


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

  • A Mantoux test: This is used to detect tuberculosis (TB) infection, especially if there's a suspicion of TB based on symptoms or exposure history.

  • A chest x-ray: This imaging test helps assess for lung conditions, including pneumonia, tuberculosis, or other pulmonary issues that might be causing the client's symptoms.

Incorrect Choices and Explanations:

  1. A nasopharyngeal swab: This is used for detecting respiratory viruses, such as influenza or COVID-19, rather than evaluating TB or general lung conditions.

  2. A pulmonary function test: This measures lung function and is used to diagnose conditions like asthma or chronic obstructive pulmonary disease (COPD), which might not be the immediate concern in an emergency setting without specific symptoms.

  3. Blood cultures: These are used to identify bacterial infections in the bloodstream rather than evaluating TB or assessing lung conditions.

Correct Answer is B

Explanation

A. This advice may lead to inadequate emptying of the breasts and imbalance in milk production, potentially affecting milk supply and infant feeding.
B. Encouraging feeding on demand promotes effective breastfeeding by allowing the infant to feed when hungry, which helps establish and maintain milk supply. This approach supports infant cues and promotes successful breastfeeding.
C. Strict time limits on feeding can interfere with effective breastfeeding and hinder milk transfer, potentially leading to inadequate nutrition for the infant.
D. Water supplementation is unnecessary for breastfed infants and can interfere with breastfeeding by reducing infant appetite for breast milk.

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