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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "I will make sure that electrical wires are run under carpeting.": This is not a safe practice. Running electrical wires under carpeting can lead to the wires overheating or becoming damaged, which is a fire hazard.

B. "I will have the heating system inspected once every 3 years.": The heating system should be inspected more frequently than every three years, ideally annually, to ensure safety and proper functioning.

C. "I will have my hearing tested every 2 years.": While hearing should be monitored regularly, this is not a specific home safety measure. A hearing impairment can increase the risk of falls or accidents.

D. "I will make sure that my hot water faucets are color-coded.": This is an important safety measure, particularly for older adults, as it helps prevent burns. Color-coded faucets can help prevent the risk of hot water burns by easily identifying hot and cold water.

A. The telephone numbers of the clients B. The room numbers of the clients C. The diagnoses of the clients D. The names of the clients' nearest relatives

Correct Answer is A

Explanation

A. Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.

B. Using the room numbers of the clients is incorrect. Room numbers can change, and relying on them increases the risk of medication errors if a client is moved or misidentified.

C. Using the diagnoses of the clients is incorrect. A diagnosis is not a unique identifier, as multiple clients in a unit may have the same or similar conditions, leading to potential confusion.

D. Using the names of the clients' nearest relatives is incorrect. Family members’ names do not provide a direct, unique way to verify the client’s identity, making them unreliable for medication administration.

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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?

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Naxlex Comprehensive Predictor Exams

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