A nurse is caring for a client who has Graves' disease. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?
Tachycardia
Hypotension
Neck pain
Respiratory depression
The Correct Answer is A
A. Tachycardia: This is correct. Tachycardia is one of the hallmark signs of thyroid storm, a life-threatening complication of hyperthyroidism (often seen in Graves' disease.. The excessive thyroid hormone leads to severe metabolic disturbances, including an increased heart rate.
B. Hypotension: Hypotension is not typically a feature of thyroid storm. In fact, thyroid storm is more commonly associated with hypertension due to the increased heart rate and metabolic activity.
C. Neck pain: Neck pain is not a common symptom of thyroid storm. Neck pain might be related to other conditions, such as thyroiditis or a goiter, but not specifically thyroid storm.
D. Respiratory depression: Respiratory depression is not a typical symptom of thyroid storm. On the contrary, thyroid storm often leads to symptoms like hyperventilation, not depressed breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I should perform a self-examination of my testicles weekly" is not recommended. Testicular self-exams should be done monthly, not weekly, as this frequency is enough to notice any changes or abnormalities.
B. "I should bear down when cupping my testes while I'm checking for abnormalities" is incorrect. There is no need to bear down during the self-examination. The testicles should be examined gently and without exerting pressure, as bearing down can make the examination uncomfortable.
C. "I should apply gentle pressure with my thumb and forefinger when examining my testes" is the correct statement. The testicular self-exam should be done gently, with light pressure to feel for any lumps or abnormalities.
D. "I should expect one testicle to be larger than the other" is a common misconception. It is normal for one testicle to be slightly larger than the other, but this should be checked regularly to ensure there are no significant changes or signs of concern.
Correct Answer is B
Explanation
A. Administer an anti-anxiety medication is not the first action. The nurse should first assess and manage the client's environment and emotional state before resorting to medication.
B. Minimize environmental stimuli in the client's surroundings is correct. The client is experiencing anxiety, and minimizing stimuli helps to reduce environmental triggers and can immediately alleviate distress.
C. Explore behaviors that have helped to reduce the client's anxiety in the past is a good intervention but should not be the first response. The immediate priority is to reduce the anxiety by controlling the environment.
D. Explain to the client that anxiety causes physical manifestations is helpful but should occur after the immediate anxiety-reduction measures are in place. Providing this information can be part of the therapeutic process but does not address the client’s immediate distress.
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